Health Systems Science I

INTRODUCTION:

-​ Lots of factors beyond our control:

-​ Medicaid and insurance issues
-​ Poor health outcomes
-​ AI
-​ Homelessness
-​ Ikigai: know your “why”

-​ Course objectives:
-​ Describe the healthcare delivery models in the US and internationally.
-​ Discuss disparities in care from a demographic and geographic perspective.
-​ Describe patient-centered care.
-​ Define value, quality, and quality improvement as it pertains to healthcare delivery and patient
satisfaction and care.
-​ Describe the models used to improve the quality of healthcare and use examples for each.
-​ Define patient safety and how it relates to quality healthcare.
-​ Identify and analyze the impact of systemic causes of errors.
-​ Describe the sources of revenue (financing) for health care, including government and private
health insurance.
-​ Describe the drivers of healthcare costs.
-​ Discuss the characteristics of a good physician leader.

-​ Block organization:
-​ Health Insurance 101 quiz (on Canvas) - 5%
-​ High Value Care Aquifer Cases and quiz (on Examsoft) - 10%
-​ LinkedIn Learning Content and Data Science of Healthcare quiz (on Examsoft) - 10%
-​ Exam: 4/25 from 1-3PM → open note - 75%

-​ Contact information:
-​ Course director: Sameer Sood, DO
-​ [email protected]
-​ [email protected]
-​ Course coordinator: Francine Silverman
-​ [email protected]
-​ 856-566-6723
THE MACRO AND MICRO OF HEALTH CARE
Joshua S. Coren
[email protected]

Learning objectives:

1.​ Understand the current health delivery system both nationally & internationally.
2.​ Understand what value means in the health care delivery system.

Learning objective #1:

-​ TOTAL SPENDING ON HEALTHCARE IN THE US:

-​ Largest sector for spending in the US with $1,842 billion in 2022
-​ Followed by Education and Pensions
-​ 18 cents on the dollar
-​ Total % of GDP: ↑
-​ 6% of GDP in 1970
-​ 18% of GDP in 2022
-​ Government health insurance is increasing as a share of health spending
-​ People used to pay more out of pocket (now less)
-​ Copays, deductibles
-​ Now more private health + government health
-​ Many employers give health insurance
-​ Different types of healthcare expenditures, growing at faster rates than before
-​ Hospital care
-​ Prescription drugs

-​ SUPPLY AND DEMAND:

-​ Baby Boomers → many over 65+
-​ Life expectancy:
-​ Average age of mortality for males and females: 78 y/o
-​ The US is 43rd
-​ Monaco, Japan, Singapore in top 3 spots
-​ Important statistics:
-​ US produces less practicing physicians per capita than average
-​ US has less annual physician visits per capita than average
-​ US has more physicians above age 55 than the average
-​ Hospital workforce: US has a nursing shortage
-​ US has less medical school graduates than average
-​ US has less acute care hospital beds per 1,000 population than average
-​ US has less hospital discharges per 1,000 population than average
-​ US has less than average % of PCP on EMR
-​ Some people are still using paper charts
-​ US has high extraordinary care / diagnostic imaging supply & use
-​ High access to MRIs, CTs, PETs
-​ Leaders to higher expense burden & cost
-​ US has higher than average number of prescription drugs taken regularly by 18+
-​ Especially with Baby Boomer increase
-​ US has high infant mortality, high % of population with 2+ chronic conditions, high
obesity rate, lower percent of population 65+
-​ But lower than average daily smokers
 -​ US has higher than average % of insufficient exercise
-​ US focuses well on exceptional needs (complex cases, high tech, etc.), but not as well on
average needs (diabetes, HTN, blood sugar, etc.)

-​ HEALTH INSURANCE IN THE US:

-​ Individual private: an individual person pays a premium (financing) directly to a “health plan”
or insurance company, which reimburses providers
-​ Offered directly from insurance companies or through marketplaces or exchanges
-​ Government: individual enrollment + taxpayers taxers → public plan that reimburses the
provider
-​ Late 1950s: < 15% of elderly had health insurance
-​ In 1965: Medicare (for elderly) and Medicaid (for poor) was enacted
-​ First tax-financed government insurance
-​ Employer private: employee/employers usually pay all or part of the premium (financing) for
their employers → health plan → reimbursement → provider
-​ Tax-deductible business expense
-​ Not counted as taxable income for the employee
-​ In essence, government is subsidizing employee-sponsored health insurance
-​ Medicare Plan Structure:
-​ Part A: hospital services
-​ Hospital insurance plan for the elderly
-​ Financed through social security taxes (SSI)
-​ Kicks in at age 65+ (paid >10 years into SSI automatically enrolled) or < 65 if
totally and permanently disabled (after 24 months of disability)
-​ Those on dialysis = usually enrolled without wait period
-​ Part B: physician services, outpatient, durable medical equipment
-​ Insures the elderly for physician’s services (specialists, PCP, etc.)
-​ Financed by federal taxes & monthly premiums from beneficiaries
-​ Available to those eligible for Medicare Part A who elect to pay the Medicare Part
B premium of $134.00/month
-​ Part D: voluntary prescription coverage that is added to original Medicare, or included in
Medicare Advantage
-​ Plans have monthly premiums in addition to that paid for Part B, average around
$30 but wide variation
-​ Deductibles vary but may not exceed $405 per year
-​ Usually different tiered formularies with different copayments
-​ Medicare Advantage Plan (“Part C”): Medicare benefits through private insurers
(private insurers manage government plan)
-​ Beneficiaries can enroll in a private health plan to receive Medicare covered
benefits
-​ Medicare pays private insurers a set monthly fee per member; insurers manage
risk
-​ Plans must cover Medicare Parts A and B, usually cover D
-​ Rules vary: referrals for speciality care, restrictions on out-of-network care
-​ Medigap: supplemental insurance, can cover copays, deductibles, + more
-​ Medicaid
-​ Based on income
-​ Federal program administered by the states, with the federal government paying 50-76%
of total Medicaid costs
-​ Required coverage includes: hospital, physician, laboratory, radiology, prenatal,
preventative, nursing home, and home health services
 -​ Pharmacy coverage is optional but currently provided in all states
-​ Covered groups: non-elderly, low income persons and the disabled
-​ No requirement for prior tax payments
-​ Evolving work requirements in some states
-​ Affordable Care Act
-​ Pre-ACA uninsured:
-​ Adults without dependent children
-​ Low income families (<400% poverty level)
-​ Moderate income families (too high to quality for Medicaid, too low to afford
private insurance, some without access to employer-sponsored insurance
coverage)
-​ Undocumented persons
-​ Goal: to decrease the # of uninsured Americans + reduce health care costs
-​ Passed in 2010, upheld in Supreme Court in 2012, 2015
-​ Currently, should people have to pay for preventative care?
-​ Expansion of coverage:
-​ Individual mandate (removed in the 2017 tax bill, effective 2019)
-​ Medicaid expansion: set the Medicaid minimum income eligibility across the US
to <138% of the federal poverty level
-​ Health insurance exchanges: competitive markets with clear information to
assist persons in purchasing insurance; subsidized for families <400% poverty
limit

-​ ACCESS TO HEALTH CARE:

-​ Uninsured rate among the nonelderly population decreased after ACA
-​ Uninsured: did not have usual source of care, did not see or speak with provider about their
health, went without needed care, postponed or did not get needed rx drug due to cost
-​ Without health insurance:
-​ Fewer regular medical visits + preventative health screenings
-​ Lower survival rates for breast and colorectal cancer
-​ Increased mortality (and greater morbidity from undiagnosed medical conditions)
-​ Less care during hospitalization
-​ Less likely to get costly test or procedure
-​ Higher in-hospital mortality rates

-​ 7 STEPS A MEDICAL STUDENT CAN TAKE:

1.​ Inform and empower your patients
-​ Understand the basics of insurance, plans, etc.
2.​ Discuss “no cost” preventative testing
a.​ Mammograms, screenings, etc.
3.​ Ask questions and address concerns
a.​ Especially about barriers, cost of care
4.​ Discuss prescription drug options and costs
a.​ Example) starting with a generic drug
5.​ Use quality measurement tools
6.​ Adapt to new payment structures
7.​ Work with other care professionals

Learning objective #2:

-​ WHAT VALUE IS:

 -​ Value = Quality / cost = outcomes + patient experience / direct + indirect costs
-​ Direct = salary
-​ Indirect = services related to care (administrative, legal, etc.)
-​ Outcomes:
-​ Disparities = race/ethnicity, SES, geography, and gender
-​ Affect mortality and health-related quality of life
-​ Determinants/factors = health care, individual behavior, social environment, physical
environment, and genetics
-​ Policies and programs will help these initiatives and address disparities

-​ DONABEDIAN MODEL:
-​ Structural measures: facilities, staff, equipment
-​ Give consumers a sense of a health care provider’s capacity, systems, and processes to
provide high-quality care
-​ Example) EMR, # of board-certified physicians, electronix Rx, patient-provider ratio
-​ Process measures: evaluations, treatments, what gets done to patients
-​ What the provider does to maintain or improve health
-​ For healthy people or for those with a health care condition dx
-​ Typically reflect generally accepted recommendations for clinical practice
-​ Can inform consumers about medical they may expect to receive for a given condition or
disease → can contribute to improving health outcomes
-​ Majority of health care quality measures used for public reporting are these
-​ Example) % of patients get preventative services, like mammograms or vx
-​ Example) % of people with diabetes who had blood sugar tested and controlled
-​ Would people want to come to your office?
-​ Outcome measures: survival, degree of health, time to recovery, disability due to care,
sustainability of health, long-term adverse consequences of care
-​ Reflect the impact of the healthcare service or intervention on the health status of pts.
-​ Example) % of patients who died as a result of surgery?
-​ Example) the rate of surgical complications of hospital-acquired infections?
-​ May represent “gold standard” in measuring quality, but an outcome results from
numerous factors, many beyond physician control
-​ Have to account for outcomes based on complexity (example: seasonal allergies
vs. end-stage renal disease) → can score complexity of patient
-​ Risk-adjustment methods: mathematical models that correct for differing
characteristics within a population, such as patient health status
-​ Still evolving, need better methods to minimize misleading/inaccurate
information about health care quality
1.​ A 40-year old man with type 2 diabetes mellitus asks physician what the likelihood is for development of
peripheral….most appropriate study design to determine this prognosis?
a.​ Cohort study
2.​ What does it mean to have health equity?
a.​ everyone is treated the same …
3.​ Considering the value equation, which of the following treatment plans is likely….musculoskeletal
spasm? -
a.​ implementation of an approach considering activity
b.​ Activity modification, core body strengthening, and OMM
4.​ A hospital wishes to implement bar coding in an effort to reduce errors…?
a.​ observing nurses and their processes
5.​ A patient states they have an allergy to penicillin yet the doctor…?
a.​ an adverse event due to negligence
6.​ What are the three dimensions of quality?
a.​ patient experience, clinical safety and effectiveness
7.​ Which of the following health policy actions…high-value care?
a.​ limiting the sale of high deductible
8.​ Which federal insurance payer is considered the payer of last resort? - medicaid
9.​ The Plan-DO-Study-Act cycle can be described by all of the following except
a.​ must utilize randomized control
10.​According to the Institute for Healthcare Improvement (IHI) leadership alliance,...?
a.​ empowerment of all participants as improvers
11.​Which best represents a critical element of patient-centered care? - involving patients
12.​How is health care insurance different than other types of insurance?
a.​ health care insurance covers both unexpected and some routine expenses.
13.​What concepts are most likely to impact your training and business in the near-term????
14.​Big data has the potential to improve delivery of value-based care through which of the following
means?
a.​ Helping to identify and develop interventions to bend the cost curve for potentially high-cost
patients
15.​Which of the following is the best way to ensure effective transitions of care
a.​ An integrated health system
FINANCING OF HEALTHCARE
Frank MacLeon

Objectives: provide a high-level understanding of health care financing

1.​ What is insurance? How is health care insurance applied?
2.​ Medical practice as a discipline
a.​ Medical Group Management Association (MGMA)
3.​ Four historical drivers impacting health care financing today
a.​ Employer-sponsored health insurance
b.​ Medicare vs. Medicaid
c.​ HIPAA
d.​ ACA
4.​ Current health care payment system and latest trends
a.​ Provider perspective

INSURANCE:
-​ What is it?
-​ Typically, for rare but significant cost events
-​ Example) college costs require savings, not insurance (anticipated)
-​ For auto (car accident, to body), homeowners (weather, wind storm, water damage, fire),
life (shorter than expected)
-​ Mostly unknown (when? how much?)
-​ Health care insurance: covers unknowns AND other events
-​ Unexpected events: injuries, hospitalizations, ER
-​ Many routine events: well visits/preventative medicine, medications, sick visits
-​ Government mandates for protection of population → vaccines, screenings, well visits

MEDICAL GROUP MANAGEMENT ASSOCIATION (MGMA):

-​ Group that supports medical practices (physician-based)
-​ Other groups for hospitals
-​ Body of knowledge (BOK) that has been developed
-​ Medical practice manager/administrator’s efforts are divided into:
-​ 29% operations management
-​ Workflow, functioning of practice itself, telephones, triage
-​ 24% financial management
-​ Profit and loss, payroll, with banks
-​ 17% human resource management
-​ Interviewing, employee reviews
-​ 15% risk and compliance management
-​ State and federal requirements for billing and documentation
-​ 8% patient-centered care
-​ Access to care, focused on the patient
-​ 7% organizational governance
-​ Owners of the entity (physicians or hospital), structural requirements
-​ Needed especially as group practice grows in size

HISTORICAL - HOW DID WE GET HERE?

-​ Employer-sponsored health insurance
-​ Great Depression in 1930s, WWII in 1940s, tax policy changes
-​ Many workers were sent to military service (limited employees)
-​ Workers’ pay frozen by the government for fear of inflation
 -​ Employers competed for workers by offering increased benefits, including Health Care
Insurance (inexpensive at the time)
-​ Results in health care insurance being linked to employment
-​ Tax-deductible
-​ Issue: declining health leads to loss of job and loss of employer-sponsored health care insurance
-​ Medicare vs. Medicaid
-​ Established in 1965
-​ Government insurance
-​ Original Medicare program:
-​ Part A: hospital insurance
-​ Part B: medical insurance
-​ Over the years, Congress has made changes to Medicare
-​ Part D: drug coverage
-​ HIPAA
-​
-​ ACA
-​

-​ Rowan is considered a covered entity

QUALITY, SAFETY, MEDICAL ERRORS, AND THE SCIENCE OF IMPROVEMENT
Dr. Childs
[email protected]

Patient Safety
-​ 5-column approach - defines components of providing quality health care
-​ Patient centered, effective, timely, efficient, and equitable
-​ STEEP - acronym for components describing quality of health care
-​ Safe
-​ Timely
-​ Effective
-​ Efficient
-​ Equitable
-​ Patient centered
-​ Ernest Codman - “fascinating story”
-​ Stated if hospitals wanted to do the right thing, they need to look into their logistics and analyze
and compare with other hospitals
-​ Created college of surgeons in 1913 - right before WWI - his ideas were abandoned
-​ Changes behavior was seen in 1965 - when medicare was created
-​ W Edwaed Deming - Father of Quality
-​ PDSA Cycles attributed to Deming
-​ Dr. Donabedian - looked at quality of health care as a structural problem
-​ Structure - Process - Outcome →
-​ Primum Non Nocere - Do No Harm - “Is what I am doing going to help the patient?”
-​ Medical Error (3rd most common cause of death in the US)
-​ Unintended Act
-​ Deviation from care process
-​ Planned Action…
-​ (missed one)
-​ Epidemiology of medical errors
-​ Experts estimate that about 98K people die in any given year from medical errors that occur in
the hospital - which is greater than the amount of people dying from motor vehicle accidents,
breast cancer, or AIDS
-​ Institute of Medicine = IOM
-​ Estimates that 44-98K unnecessary deaths per year due to medical error
-​ 1 million excess injuries due to medical error
-​ Total cost of adverse events is btwn $17-29 billion (numbers based on HMPS)
-​ IOM findings
-​ Medical errors are serious
-​ The cause is bad systems
-​ We need to redesign out systems
-​ We need to make a safety a national priority
-​ Bad systems and not bad people lead to the most errors
-​ Deaths due to medical error
-​ More deaths in America every 6 months than those who died in Vietnam War
-​ Performance measurement - for a hospital to be accredited, they need to able to measure link between
performance and measurement
-​ Potential Solutions
-​ Learn lessons from other industries
-​ Development of IT infrastructures
-​ Restriction of working hours
 -​ AAMC proposed guidelines = 80 hour weeks
-​ Greater staffing to patient ratios
-​ Organizational culture

Slide 33:
-​ HARVARD STUDY
-​ Example) errors like “I’m allergic to penicillin but what given penicillin.”
-​ FINDINGS:
-​ At least one adverse
-​ Health-care associated infections = developed in hospitals
-​ **NEAR MISSES = important!!!
-​ Physicians often would not admit that something went wrong

ERROR:
-​ Error: failure of a planned action to be completed as intended (i.e. error of execution) or the use of a
wrong plan to achieve an aim (i.e. error of planning)
-​ Adverse event: an injury that is most frequently caused by medical or surgical management rather than
the underlying disease
-​ Not all adverse outcomes are the result of an error
-​ Only preventable adverse events are attributed to medical error
-​ Adverse events may cause harm or not
-​ Preventable adverse events: Those that occur due to error or failure to apply an accepted strategy for
prevention
-​ Ameliorable adverse events : events that while not preventable could have been less harmful if care had
been different
-​ Adverse events due to negligence : those that occur due to care that falls below the standards expected
of clinicians in the community
-​ Sentinel events = MUST BE reported
-​ Any unexpected loss of life
-​ Wrong side surgery
-​ Inpatient suicide
-​ Patient abduction

Q. HOW OFTEN DOES WRONG SITE/WRONG PROCEDURE /WRONG PATIENT SURGERY OCCUR
IN THE UNITED STATES??
A. 40 times a week

Relationship of medical errors to adverse events:

Medical negligence: failure to meet the standard of practice of an average qualified physician practicing in the
specialty in question
-​ Occurs not merely when there is an error, but when the degree of error exceeds the accepted norm
-​ Negligent medical injuries = 1-2% of all hospitalizations
-​ But 42% of public reported a medical error
-​ 66% reported serious consequences such as severe pain, substantial loss of time at work or school,
disability, or even death
-​ Only 6% had sued
-​ Insert slide 48
-​

SWISS CHEESE MODEL:

Take home points:

-​ Reason's Swiss Cheese Model, in which multiple errors combine to create major adverse events because
of inadequate defenses, explains many adverse events in health care
-​ Analysis of adverse events should focus on discovering which defenses failed and bolstering them
-​ To prevent wrong-site/wrong-patient procedures, hospitals should implement Universal Protocol
-​ Example) mark placed on site of surgery
Slide 64:
-​ Examples of mistakes
-​ ALSO taking the wrong patient down for a procedure → dismissing them

Human factors principles

-​ Avoid reliance on memory
-​ Simplify
-​ Standardize
-​ Use constraints and forcing functions (forces us to look at potential for adverse events)
-​ Use protocols and checklists wisely
-​ IMPORTANT!! Used across industries (nuclear, military)
-​ The Checklist Manifesto by Atul Gawande
Given the reality what do we need to do
-​ Follow guidelines
-​ Double check if you do not know
-​ Write clearly and carefully
-​ Print, avoid abbreviations
 -​ Use leading “zero’s” and do not use trailing “zero’s)
-​ Ask questions - never a bad question
-​ JUST CULTURE - Frontline personnel feel comfortable disclosing medical errors while
mainitaining professional accoutability. Just culture recognizes that competent
professionals make mistakes
-​ Stop the line mentality - ie a car going through a line - if someone sees a problem, they
don't want to be the ones to report the problem. Don’t be afraid to stop the line from
moving and let the mistake go through!
-​ Error is inevitable and usually pertaining to system flaws and not character flaws
-​ Healthcare in the world of Covid 19
-​ Burnout → Increased patient safety incidents and medical errors → Low quality of care (STEEP)
→ Healthcare provider psychologically ill mental health → leads back to Burnout

1.​ On average which of the following is the best predictor of ones health
a.​ Whether or not you are wealthy
2.​ According to the 2022 federal poverty guidelines, what is the gross income for a family of four?
a.​ 27,750
3.​ While working to increase access to and coordinate medical care for a defined population, what other
model care can also reduce costs of care
a.​ Reducing unnecessary
4.​ Which of the following is an example of a non-verbal cue when interacting with a patient
a.​ Tone of voice
5.​ Which country has routinely spent the most in terms of GDP, per capita, or total spend on health care
yet appreciates the lowest return in terms of quality
a.​ United States
6.​ Which of the following is one of the most effective ways to ensure patient safety
a.​ A clear and concise check list
7.​ What are the three dimensions of quality
a.​ Patient experience, clinical safety, and effectiveness
8.​ Which of the following is a cited reason for malpractice litigation
a.​ Physician being curt and ignoring patient questions
9.​ Which of the following is covered by part B Medicare
a.​ Office expense
10.​Which of the following is the most important reason for improving patient engagement
a.​ Evidence shows that more engaged patients show better outcomes
11.​In the “when the bough breaks” video
a.​ Lack of prenatal care
12.​Choosing wisely is a national campaign that aims to provide high value care
a.​ Payment reforms to help implement
13.​Which of the following has the lowest contribution to healthcare spending
a.​ Out of pocket spending
14.​What initial steps should a practice leader take to help individual physicians reduce overuse of imaging
a.​ Work with others to identify …
15.​The rationale for clinician leadership includes which of the following
a.​ There is evidence of improved patient outcomes when utilized
HIGH RELIABILITY, JUST CULTURE, AND THE SCIENCE OF IMPROVEMENT
Dr. Childs
[email protected]

“TENERIFE” - THE SEQUENCE OF EVENTS (1977)

-​ What happened:
1.​ Single-runway airport on the small island of Tenerife (Canary Islands, coast of Africa)
2.​ Botched terrorist explosion at main island → shutdown of all inbound and outbound flights
3.​ Arriving flights with too little fuel had to land at Tenerife → more planes than that airport was
designed to handle
a.​ 2 large Boeing 747s were too heavy for one half of the existing taxiways
4.​ Communication: the 2 tower controllers had limited ability to speak “Aviation English” (required
international language of air traffic control)
5.​ Weather: light fog became solid fog
6.​ Very experienced pilot on the KLM 747 (widely presumed to be perfect)
a.​ Decided to let passengers off the plane rather than keep them on the plane in case of rapid
departure (had to send crew members to terminals to round up passengers)
7.​ Refueled the plane (too much fuel) to make it back to Amsterdam → plane too heavy for takeoff
on the short runway
8.​ Pilot wanted to keep the operation on schedule + adhere to crew duty-time limitations → may
cost company $30,000 to hold plane over to accommodate crew duty hours (hotels, etc)
9.​ Pilot preps for takeoff (finishes the engine start procedure with 10 minutes crew duty-time
deadline) → releases the brakes
10.​Follows control tower’s “heavily accented” instructions to taxi down runway and turn around in
position to be the first aircraft off
11.​Solid fog → tower cannot see planes on the runway, so depending on verbal communication with
pilots who are receiving taxi clearances as well (congested area at the west end)
12.​KLM positioned for takeoff, pilot verifies copilot finished checklist
a.​ At this time, Pan Am Aircraft is taxiing to turn onto Exit Three to wait for take off orders

13.​Copilot notices pilot is starting takeoff roll without takeoff clearance from tower
a.​ Tells pilot “We do not have clearance!”
14.​Pilot pulls the throttle back and says “I know that! Get the clearance!”
a.​ Fog increasing; pressure to take off immediately
15.​Copilot contacts the tower for clearance
a.​ Spanish tower controller gives first level clearance to Dutch plane crew (second required
for takeoff) → copilot writes it down and reads it back to assure no mistakes
b.​ Captain pushes up throttle for takeoff (still no clearance for takeoff)
16.​Copilot reluctant to point out mistakes to pilot (a second time)
a.​ Decides to clear himself for takeoff, assuming the tower will tell them to stay put
b.​ Adds the phrase “And… now we are at takeoff!”
17.​Copilot does not use Aviation English in takeoff position
a.​ Tower controller hears what he thinks he should and says “okay”, still unsure of the
 message, then adds “standby, will call you”
18.​At same time, another pilot asks for clarification of phrase, but it does not go through
a.​ 2 transmitters on the same frequency at the same time produces a large squeal
b.​ Only communication heard was “okay” → failed to understand each other under pressure
19.​KLM plane accelerates down the runway for takeoff → collision into Pan Am plane
20.​Consequence: all 248 passengers and crew aboard the KLM plane died, as did 335
passengers and crew aboard the Pan Am plane
-​ Probable cause:

-​ The investigation concluded that the fundamental cause of the accident was that The KLM
Captain attempted to take off without clearance. The investigators suggested the reason for this
was a desire to leave as soon as possible in order to comply with KLM's duty-time regulations
(which went in place earlier that year) and before the weather deteriorated further.
-​ Other major factors contributing to the accident were:
-​ The sudden fog greatly limited visibility. The control tower and the crews of both planes
were unable to see one another.
-​ Airport could not handle 747
-​ Interference from simultaneous radio transmissions, with the result that it was difficult to
hear the message.
-​ Use of ambiguous non-standard phrases by the KLM co-pilot ("We're at take off") and the
Tenerife control tower ("OK").
-​ The Pan Am aircraft had not left the runway at the third intersection.
-​ Had missed the 3rd exit and was heading to 4th exit.
-​ The airport was forced to accommodate a great number of large aircraft due to rerouting
from the terrorist incident, resulting in disruption of the normal use of taxiways
-​ The crowded airport had placed additional pressure on all parties, including the KLM
cockpit crew, the Pan Am cockpit crew, and the controller;
-​ Sounds on the CVR suggested that during the accident the Spanish control tower crew
had been listening to a soccer match on the radio and may have been distracted
-​ The transmission from the tower in which the controller passed KLM their ATC
clearance was ambiguous and could have been interpreted as also giving take-off
clearance.
-​ In support of this part of their response, the Dutch investigators pointed out that
Pan Am's messages "No! Eh?" and "We are still taxiing down the runway, the
Clipper 1736!" indicated that captain Grubbs and first officer Bragg had
recognized the ambiguity (this message was not audible to the control tower or
KLM crew due to simultaneous cross-communication)
-​ Lessons learned:
-​ Themes of contributing causes:
-​ Perceptions
-​ Assumptions
-​ Botched communication
-​ Never just one cause in such an event
-​ Human error and bias
-​ Stress and fatigue
-​ Lack of safety culture – stop the line
-​ Quality Improvement is about assuring safety
-​ Airline industry revised processes after Tenerife
-​ Crew resource management:
-​ Methodology in which the resources of equipment, procedure and people are collectively utilized
as needed to safely complete every flying task.
 -​ The individual components of CRM resources are communications, situational awareness,
problem solving, decision making making and teamwork
-​ SBAR: situation, background, assessment, recommendation
-​ Present things all in the same way

SOLUTIONS: CREATE HIGH RELIABLE SYSTEMS

-​ High Reliability Organizations: complex, high-risk organizations that manage to deliver the right
outcomes each and every time, despite human error and unsafe systems.
-​ Use behaviors, leadership and accountability to provide additional safety nets for systems that
are high risk
-​ Respond to a wide variety of situations under changing environmental conditions in a reliable
and consistent way
-​ Have an extraordinary capacity to discover and manage unexpected events resulting in
exceptional safety and consistent levels of performance
-​ High Reliability is endorsed by the Agency for Healthcare Research and Quality (AHRQ) and
the Joint Commission.
-​ Analogous to amusement parks, military, etc.
-​ Five Principles of HROs:
-​ Three principles of anticipation
-​ Preoccupation with failure: Inconsequential errors are a symptom of something going
wrong
-​ Sensitivity to operations: Paying attention to whats happening on the front lines
-​ Reluctance to simplify: Encouraging diversity in experience, perspective and opinion
-​ Two principles of containment:
-​ Commitment to resilience: Developing the capabilities to detect, contain, and bounce
back from events that do occur
-​ Deference to expertise: Pushing decision making down and around to the person with
the most related knowledgeledge and expertise
-​ Example) Alaska Airlines grounds 737 when window blows out
-​ Recurring themes for organizational focus:
-​ Leaders’ and managers’ emphasis and demonstration that safety and quality are high priority
(driving culture)
-​ Teamwork (across units/departments and handoffs of patients)
-​ Staff communication about risks and reporting of events and near misses
-​ HROs: similar to health care
-​ They operate in unforgiving social and political environments
-​ Their technologies are risky and present potential for error
-​ The scale of potential consequences from errors precludes learning through experimentation
-​ Complex processes are utilized to manage complex technologies

THE BALANCE OF JUST CULTURE:

-​ Balance of punitive culture (individuals blamed for all mistakes) and blame-free (all errors to system
failure; no individuals is to be held accountable)
-​ Active failure:
-​ Errors
-​ An action does not go as intended → lapse/slip
-​ An action goes as it was intended but it’s the wrong action → mistake
-​ Violations
-​ A deliberate deviation from an operating procedure, standard, or rule
 -​ Key words: reckless behavior, at-risk behavior, console, coach, punish
-​ Example of a coach) telling people to wash their hands, showing stats
-​ Just culture algorithm helps organizations and managers determine which acts represent human errors,
“at-risk” behaviors, and examples of negligence
-​ Organizational leaders need to study such models and work toward creating a culture that supports
safety

TRANSFER OF EVIDENCE INTO CLINICAL PRACTICE:

“An average of 17 years is required for new knowledge generated by randomized controlled trials to be
incorporated into practice. Even then, application is highly uneven…”
-​ Randomized controlled trials (scientific method) → may not lend well to complex systems / less useful
as “truth standard” at clinical level b/c healthcare systems are complicated
-​ Many other influences and variables that cannot be reflected in typical scientific methods
-​ Complexity of healthcare:
-​ So many touch points for one patients (each is an area potential for error)
-​ Hard to make a controlled study
-​ Takes YEARS to bring about change
-​ Reducing the system to its parts in order to study it is a barrier to understanding the whole
-​ Inspecting the legs, body, neck and head separately and expecting to understand how a
giraffe works
-​ Instead of pursuing such reductionism, complexity scientists aim to study the properties and
characteristics of the system
-​ Complicated vs. complex system:
-​ COMPLICATED: consider a hospital, viewed from afar
-​ Several buildings, beds, and staff
-​ Treats 70,000 inpatients annually
-​ May have large budget of millions of dollars
-​ Management structure, with multiple layers and hierarchies: macro, meso, & micro levels
-​ Complicated: meaning that there’s a lot going on with all the components
-​ A complicated system may still be predictable if interactions occur in a relatively
simple way
-​ COMPLEX: look deeper inside, at the ecosystem level
-​ Interacting people
-​ Cliques
-​ Clinical professionals
-​ Informal and formal groups and terms
 -​ Various units and departments
-​ Implications of Complexity of Research
-​ Need to factor in uncertainty, context, culture, and features of complexity
-​ Need to factor in how to study design and develop strategies for indepth studying
-​ Create generilizable and transferable knowledge
-​ The science of improvement
-​ Characteristics
-​ Aims to generate local wisdom and generilizable or transferable knowlegge
-​ Use of quality data
-​ Applies well established credible research models ​
-​ Challenges
-​ Too many quality improvement projects rely on contemporaneous, non-standardized,
unverified data to make judgments about their effectiveness
-​ Choice of methods is often guided by pragmatism
-​ Implementation of interventions and data collection in
-​ complicated, highly heterogeneous real-life situations
-​ Lack of an improvement scientific approach
-​ Much quality improvement work is unscientific
-​ Urge to act can easily overwhelm the need for evidence to inform that action
-​ Not informed by high-quality evidence
-​ Not subject to rigorous assessment to establish its effectiveness, costs, and risks
-​
-​ Impact
-​ Might lead to outcomes that are exactly the opposite of what is intended by
improvement efforts
-​ Resources can be wasted
-​ Energy and enthusiasm are dissipated
-​ Side-effects of interventions may be ignored
-​ Little positive change may be evident
-​ 7 Propositions to Guide the Science of Improvement (SOI)
1.​ Is grounded in testing and learning cycles – this leads to the justification of Plan-Do-Study-Act
(PDSA) cycles as an approach that is aligned with the scientific method
2.​ Its philosophical foundation is conceptualistic pragmatism – this leads to the importance of
using prior and existing knowledge to form theories or develop changes and make predictions
of what will happen as these changes are applied
3.​ ​ Embraces a combination of psychology and logic - provides the basis for
multidisciplinary collaboration and the value of addressing problems from different
perspectives.
4.​ Considers the contexts of justification and discovery
a.​ Improvement efforts always involve an element of discovery and creativity in problem
solving
b.​ However, these activities must be balanced by some form of
c.​ Justification
i.​ Using data to know if our tests of change worked, how well they worked
ii.​ What our next steps should be (eg, abandon the test, revise it, try it in another
area)
5.​ Considers the contexts of justification and discovery
6.​ Requires the use of operational definitions
a.​ Stresses the need to develop clear and consistent definitions of the terms​ used and to
take care that others involved in improvement understand these definitions so they can
have a shared understanding
 b.​ Different measures for different purposes:

c.​ Model for improvement:

d.​ The plan-do-study-act cycle

i.​ Example) a person in the office will call the patients the day before to make sure
they are attending their appointment → then checking data after 3 months to see if
it worked
7.​ SOI employs Shewhart’s theory of cause systems
a.​ Understanding variation here means using tools (Shewhart charts) to understand whether
a process is stable and to distinguish between special and common cause variation
-​ Models for improvement:

Gonna kms that was rough - brotha jus spoke…SOOO MUCHHH

KNOW STEEP​
GUIDELINES FROM HROS
GUIDELINES FOR JUST CULTURE
1.​ What is healthcare expenditures as a percentage of gross domestic product (GDP)? - 18%
2.​ Which of the following best describes healthcare disparities? –
a.​ healthcare differences that are linked to social economic, and/or environmental disadvantage
3.​ What is essential for a sustainable universal health coverage? - services are made available to entire
population consistent with funds available???
4.​ Which group of women have the worst maternal mortality rates out of all…?
a.​ African Americans
5.​ What is the aim of universal health coverage?
a.​ To assure the population have access to ALL services free of charge
6.​ Andrea is a third year medical student hoping to match … Which of the following statements represents
a quality improvement initiative designed to reduce the rate of postoperative DVT?
a.​ A multi-instiutional cohort study
7.​ When entering prescriptions for medications, the physician takes advantage of CPOE..?
a.​ CPOE allows quicker transmission of orders to the ER room nurses

8.​ Which of the following statements is true about a capitated reimbursement mechanism?
a.​ It increases certainty about how much money will spend on its enrollees
9.​ WHich of the following best describes the framework for improvements in healthcare delivery in this
question? - Donabedian Model for care quality
10.​Wide variation in delivery care may interfere with delivering high value care. Which of the following may
contribute to variations in care?
a.​ Fee for service medicine where providers are paid based …
11.​Dorothy is a nurse manager at the hepatology clinic …? - Efficient
12.​What does it mean to have health equity?
a.​ All persons have equal access and also necessitates actions to ensure that added obstacles are
addressed for vulnerable groups
13.​Which of the following is converted by part A Medicare? - hospital expenses
14.​What components constitute the triple aim goals?
a.​ enhanced member experience, lowers cost, improved quality
15.​What is the best way to assess performance of a healthcare delivery unit? - Use data based upon some
agreed upon metric like customer satisfaction or relative value units
16.​A senior medical student is working on a quality improvement project with her adviser … ? - For the
next 50 patients …
17.​Prior to discharge from the hospital, patients admitted for exacerbation surgery of asthma …? - Follow
up appointment in one week???
18.​Choosing wisely is a national campaign that aims to provide high value care that is … ? - Payment
reforms to help implement clinical practice improvement initiatives
19.​Before surgery, the patient expresses a preference for post-operative …? - social worker
20.​What initial steps should a practice leader take to help individual physicians reduce overuse of
imaging? - distribute copies of guidelines on imaging for low back pain
VALUE IN HEALTHCARE
Eric J. Berman, DO

Objectives:

1.​ Define value in healthcare and identify core concepts

2.​ Demonstrate how we stack up in the global economy
3.​ Discuss how providers and facilities are reimbursed
a.​ Traditional models
b.​ Alternate models
4.​ Explore how value will be defined and achieved as healthcare transforms

Objective #1:

-​ WHAT IS VALUE?
-​ Defining it:
-​ Value: relative worth, merit, or importance as in commerce or trade of money, material,
services, etc.
-​ In sociology: the ideals, customs, or institutions of a society toward which the
people of the group have an affective regard
-​ Ethics: any object or quality desirable as a means or as an end in itself
-​ Who is performing the valuation?
-​ Consumer: individual, group (small, medium, large, jumbo)
-​ Commercial
-​ Fully-insured (FI)
-​ Administrative Services Only (ASO)
-​ Government Programs
-​ Medicaid
-​ Medicaid
-​ Concierge Care/Direct Primary Care/etc
-​ Provider
-​ Facility: integrated delivery system, hospital system, Accountable Care
Organization, hospital, surgical center, Urgicare center, etc.
-​ Physician, nurse practitioner, pharmacist, etc.
-​ Pharmaceutical industry/pharmacies
-​ Payer/insurer
-​ Ancillary services (imaging, lab work, DME, home care, PT/OT/ST, etc.)
-​ WHAT IS HEALTHCARE?
-​ The system charged to address the physical and behavioral health needs of the population served
-​ More narrow than broader concept of wellness (which includes physical, behavioral, social,
economical, and spiritual well-being)

-​ CORE CONCEPTS
-​ Cost:
-​ How is cost calculated?
-​ Total spend = unit cost x utilization
-​ Unit cost: amount we pay for item or service
-​ Utilization: amount or frequency with which an item or service is used
-​ How is cost measured?
-​ Gross Domestic Product (GDP)
-​ Per capita spend
 -​ Medical Loss Ratio (MLR)/Medical Cost Ratio (MCR)
-​ Quality:
-​ How is quality measured and what drives it?
-​ Objective measures:
-​ Life expectancy
-​ Morbidity and mortality,
-​ National Committee for Quality Assurance (NCQA)
-​ Healthcare Effectiveness Data and Information Set (HEDIS)
-​ Star measures
-​ Utilization Review Accreditation Commission (URAC)
-​ Joint Commission on accreditation of Health Care Organizations (JCAHO,
now The Joint Commission)
-​ Subjective measures:
-​ Customer Assessment of Healthcare Providers and Systems (CAHPS)
-​ Available online
-​ Customers satisfaction surveys (e.g. Press Ganey: Healthcare Analytics
Experience)
-​ Performance:
-​ How do the facilities, systems, companies rank? - Obtained from
consumer reports ​
-​ Both cost and quality:
-​ Can some measures count for both cost and quality (rated in Stars, HEDIS)?
-​ Potentially preventable events:
-​ Initial admissions
-​ Readmissions
-​ ER visits
-​ Ancillary services
-​ Example) imaging studies, lab studies
-​ Medication adherence
-​ Higher adherence, avoid readmission
-​ Access:
-​ How is access measured and achieved?
-​ Network adequacy
-​ Facilities, specialties, ancillary services
-​ Meeting established parameters for distance and time
-​ Driven by regulation and/or market pressure
​
Objective #2:

-​ RISING COST OF HEALTHCARE IN THE U.S.:

-​ Spending on health care in US rising at a faster face than spending in the rest of the economy
since the 1960s
-​ 2005: national health care spending amounted to $2 trillion, or $6697 per person and about 16%
of the gross domestic product (GDP)
-​ 2015: national health care spending amounted to $4 trillion and about 20% of the GDP
-​ Delayed by passage and implementation of the PPACA in 2010 but was achieved at the
close of 2021 and reached $4.5 trillion by 2022
-​ Rise plateaued to 4-6% as opposed to the normal 12% rise

-​ STATISTICS/GRAPHS:
-​ US spends higher percentage of GDP and per capita spending on health care
 -​ We spend a lot on health care, and less on social services/prevention
-​ US ranks low in life expectancy and poorly on infant mortality
-​ US ranks low in maternal mortality and low birth weight as well
-​ US ranks worse in obesity, # of MRI, health spending, etc.
-​ US only ranks better in smoking rates
-​ Conclusion: we spend the most, but we do not live longer and we are the sickest

-​ STUDIES:
-​ Health Care Spending in the United States and Other High-Income Countries
-​ Spent 2x as much
-​ Utilization rates are the same
-​ Due to higher costs of labor, foods, pharmaceuticals
-​ KFF Poll: Half of US Adults Avoided Care in the Past year Due to Costs
-​ Failing to take medications as prescribed
-​ Many people over 65 paying for various aspects of health care not covered by Medicaid
-​ US comes in last in health care rankings of high-income countries
-​ 11 countries observed in the study - US did not have universal health care coverage

Objective #3:

-​ REIMBURSEMENT MODELS:
-​ Traditional payments:
-​ Fee for service: payment for services rendered, typically Specialist
-​ Example) cardiologist doing an EKG, stress test, etc.
-​ More you do, the more you make
-​ Capitation: payment for each member enrolled in a practice, typically PCP
-​ Example) $10/person/month from Horizon
-​ Sometimes paid physicians to do less
-​ Alternate models:
-​ Resource Based Relative Value Scale (RBRVS), Medicare: the physician payment
system used by Centers for Medicare & Medicaid Services (CMS) and most other payers
-​ Instead of basing payments on charges, the federal government established a
standardized physician payment schedule
-​ RBRVS is the name given to the database
-​ 3 components hold the actual values and include the work RVU, the practice
expense RVU (bandages, sutures, etc.), and the malpractice expense RVU
-​ Standard units of measurement in RBRVS database
-​ Percentage of Medicare: commercial and Medicaid
-​
-​ Inverted Traditional Payment: PCP as FFS (fee for service) and Specialists as
Capitation
-​ Episodes of Care: payment covers pre-op, op, post-op and rehab inclusive of
complications [based on intensity of illness]
-​ Increased/decreased every few months throughout management
-​ Has to be risk-adjusted for patients with multiple comorbidities
-​ Case rates: all inclusive payment for an individual encounter (e.g. Urgicare center)
-​ Example) surgical specialists, breast surgeries
-​ Includes complications, but incentivizes good outcomes
-​ Diagnosis Related Group (DRG): payment based on Medicare Severity (MS)
-​ For the main diagnosis that caused the hospitalization plus up to 24 secondary
diagnosis + can figure in other factors like age and gender
 -​ If hospital spends less on your treatment than their payment → more $
-​ If hospital the spends more on your treatment than their payment → lose $
-​ Per diem: daily payment based on the level of care rendered

-​ WHERE MIGHT REIMBURSEMENT MODELS LAND?

-​ Value based payment (VBP): a strategy used by purchasers to promote quality and value of
health care services
-​ Goal: shift from pure volume-based payments (like fee-for-services payments) to
payments that are most closely related to outcome
-​ Helps avoid unnecessary tests, incentives good outcomes
-​ Shared savings: entity and payer share the savings if actual performance exceeds
baseline or expected
-​ May include a cap on the amount of potential savings
-​ Partial risk: entity takes upside risk
-​ Entity earns increased payments or bonus for actual performance EXCEEDING
expected performance which may be tied to degree of improvement
-​ Full risk: entity takes upside and downside risk
-​ Entity earns increased payments or bonus for actual performance EXCEEDING
expected performance and incur penalties or reduced payments for actual
performance BELOW expected performance

Objective #4:

-​ FINANCIAL PERFORMANCE: HOW IS EACH DOLLAR SPENT?

-​ Medical Loss/Cost Ratio (~85%): payments made to hospitals, doctors, for prescription drugs
-​ Administrative Loss/Cost Ratio (~12%): payments for operating costs of the business
-​ Dealing with complaints, appeals, etc.
-​ Margin (~0.5-3%): remaining profit
-​ Underwriting margin:
-​ Premiums, admin fees, and other revenues: premium payments and fees received from
out members
-​ Medical costs: payments made to doctors, hospitals, and for prescription drugs
-​ SG&A: operating costs of the business
-​ Margin ranges in 2018:
-​ Pharma and biotech: 22-37%
-​ Casinos: 0.5-25%
-​ Publicly traded insurers: 6-9%
-​ Select NJ hospitals: 4-5%
-​ Not-for-profit insurers: <1-3%

-​ THE TRIPLE AIM:

-​ Core
-​ Health
-​ Cost
-​ THE QUADRUPLE AIM:
-​ Triple Aim + Enhanced Provider Experience
-​ Aim to reduce burden of practice for provider

-​ GENERAL POPULATION STRATIFICATION & RISK ADJUSTMENT

-​ Relative super utilizers (RSU) = drive 75-90% of health care costs, but make up 1-3% of the
population
 -​ At risk = poorly managed conditions like obesity, HTN, etc.

-​ SELECT POPULATION STRATIFICATION & RISK ADJUSTMENT

-​ Older populations with the medicare advantage (most have at least 1 chronic condition)

-​ TRANSITION OF CARE CHECKLIST:

1.​ Conduct a medication reconciliation to:
a.​ Simplify the member’s medication regimen → support medication adherence
b.​ Ensure payer formulary or generic equivalents are used → optimize cost savings
c.​ Synchronize mediation fills → minimizes confused with multiple medications
d.​ Ensure medications are delivered to home or place of convalescence within 24 hours of
need of identification or DC from an IP facility
2.​ Ensure required DME is delivered to the home or place of convalescence within 24 hours of need
identification or DC from an IP facility
3.​ Conduct a home visit or call within 48 hours of need identification of DC from an IP facility to:
a.​ Answer remaining questions
b.​ Perform needed evaluations or examinations
c.​ Conduct an environmental assessment
4.​ Schedule a visit with the PCP or treating specialist within 7 days of need identification or DC
from an IP facility
5.​ Evaluate the member for home monitoring when clinically appropriate
6.​ Evaluate the need for palliative care
7.​ Evaluate the need for hospice care

-​ WHAT WILL TRUMPIE BRING?

-​ Pros
-​ Level the economic playing field through extreme and broad tariffs
 -​ Eliminate waste
-​ Shrink government
-​ Return American manufacturing
-​ MAGA/MAHA
-​ Cons
-​ Stock market is tanking along with the economy stability and predictability
-​ Trust in America as a brand is eroding
-​ Brain drain with students and researchers looking to Europe and other options →
negatively impacting innovation
-​ Job loss from massive layoffs
-​ Negative impact on SoDH and overall health, financial stability, education, etc.

1.​ Which of the following is true about the process of using Plan-Do-Study-Act (PDSA) cycles for quality
improvement? - PDSA cycles often begin as a small pilot intervention or test of change and are
repeated with slight modifications to allow iterative change
2.​ What is the quadruple aim in healthcare? - increase quality care, appropritate cost, patient satisfaction,
physician satisfaction
3.​ Which group of women have the worst maternal mortality rate in US
a.​ African American
4.​ The rationale for clinician leadership includes which of the following?
a.​ There is evidence of improved patient outcomes
5.​ Which of the following is true regarding MEdicare advantage?
a.​ Are a fee for service reimbursement plan
6.​ Electronic health records seek to provide patients with an electronic copy of their health information…
Which one of the following meaningful use priorities is addressed by this service?
a.​ Engage patients and families
7.​ Mrs. Susan Smith is a 56 year old…Which of the following attributes is the most characteristic of this
type of occurrence?
a.​ Preventable
8.​ A family physician in a town located more than 20 miles from the nearest hospital chooses to
discontinue…WHich of the following patient safety issues is most important to address?
a.​ Communicating adequately with the hospitalist during care transitions
9.​ What is Work relative value unit a measure of
a.​ Work effort provided by physician
10.​Currently and for the last decade. Hopeitworks…what type of reimbursement arrangement does the
practice currently have?
a.​ Fee-for-service
11.​What is the quad. Aim in healthcare
a.​ Increase quality, app costs, patient satis,physician satis
12.​Which of following true regarding social determ of health?
a.​ Conditions in which people born, live, work and age
13.​Health insurance marketplaces, commonly referred to as health exchanges…
a.​ Because employers generally pay a portion…
14.​What best answer every physician should consider prior to ordering an imaging…
a.​ The pretest probability of the disease in question is for that individual
15.​Which of following most likely to prevent medication errors?
a.​ Computer. Prescrip. Entry and medication dispens
16.​Choosing wisely is a national campaign…which of thefollowing is a potential barrier to adopting these
guideline?
a.​ Current medical malpractice
17.​What is healthcare expenditures as a percentage of GDP?
a.​ 18%
18.​the international statistical classification of diseases and related health problems (ICD-10) is coding
standard to do what?
a.​ Coding standard to identify diseases
19.​What is a health benefits package?
a.​ Set of services that can be feasibly financed
20.​What is a characteristic of high reliability Organization
a.​ Have an extraordinary capacity to discover and manage unexpected events?
21.​WHich of the following holds promise to broadly evaluate ways to understand and improve the
value/cost equation?
a.​ Developing a 12-week program…..
22.​Regional hospital sys. Decided to institue a new task group for quality improvem. Which of the following
interventions has the most success. In achieving the task group mission?
a.​ Changing electronic medical records to only allowing a mx 7
23.​Which of the following has the lowest contribution of healthcare spending?\
a.​ Medicaid
24.​According to the institute of Healthcare Improvement (IHI) leadership alliance, the four mental
models….
a.​ Empowerment of all participants as improvers
25.​which of the following is a known contributor to unnecessary antibiotic prescribing?
a.​ Patient demand
26.​Which of the following is a cited reason for malpractice litigation?
a.​ Physician being curt and ignoring patient questions
27.​Mrs.Susan Smith…what is the best way to classify the error described in this scenario?
a.​ Preventable adverse event
28.​Which best represents a critical element of patient-centered care?
a.​ Involving patients in medical decision making
29.​Patient was recently hospitalized and started on increased dose of blood pressure medication
a.​ Preventable adverse event
30.​A hospitalist is experiencing a busier than usual day…this approach is most likely to result in which of
the following?
a.​ Nurses being less willing to admit mistakes
LEADERSHIP IN HEALTHCARE
Dr. Whebe
[email protected]

OBJECTIVES
-​ Leadership definition
-​ Outlining leadership styles
-​ Organizational structures
-​ Key areas of focus for healthcare leaders

WHAT IS LEADERSHIP
-​ Leadership is a process of social influence, which maximizes the efforts of others, toward the
achievement of a goal
-​ Leadership styles: 6 leadership styles
-​ Coercive
-​ Pace setting
-​ Coaching
-​ Democratic
-​ Affiliative
-​ Authoritative
-​ Primary leadership styles
-​ Colaborator: Empathetic, teambuilding, talent spotting, coaching oriented
-​ Energizer: Charismatic, inspiring, connects emotionally, provides meaning
-​ Pilot: Staretic, visionary, adroit at managing complexity, open to input, team-oriented
-​ Provider: Action-oriented, confident in own path or methodology, loyal to colleagues, driven to
provide for others
-​ Harmonizer: Reliable, quality driven, execution-focused, creates positive and stable
enviornemetns, inspires loyalty
-​ Forecaster: Learning oriented, deeply knowledgable, visionary, cautious decision making
-​ Producer: Task focused, results oriented, linear thinker, loyal to tradition
-​ Composer: Independent, creative, problem solving, decisive, selt-reliant
SERVANT LEADERSHIP

-​ Leadership education has been around since the 1970s

-​ The main tenets of Servant Leadership = Empathy
-​ Empathy is understanding a person and seeing things through their eyes and their perspective
-​ William Mayo utalizes servant leadership at the Mayo Clinic

Shift in health care system: takes about 17 years for something to become standard of care
-​ Healthcare quality and equity
-​ Patient safety
-​ Population health: looking at a certain population and the influences on that population and tracking
their healthcare outcomes, as well as the decisions that influence those outcomes
-​ Operations: operational efficiencies
-​ Compliance with new laws and regulations
-​ Work environment
-​ Quadruple aim: 4 things that improve patient outcomes
-​ Improved clinical outcomes
-​ Improved efficiency
-​ Patient experience
-​ Clinician experience
ORGANIZATIONAL STRUCTURE
-​ Place the patient-physician relationship at the center
-​ Focus on…
-​ Cost
-​ Quality
-​ Patient experience
-​ Provider care practices: physician satisfaction

PHYSICIAN LEADER FOCUS

-​ Patienc centric
-​ Clinial leadership
-​ Outcome driven
-​ Team collaboration
Qualities of a good physician
-​ Medical knowledge: exhibit proficient knowledge of biomedical, clinical, and cognate sciences, and
application of patient care
-​ Patient care: provide compassionate, appropriate, effective patient care
-​ Practice-based learning and improvement: continually assess and evaluate patient care practices and
assess and assimilate scientific evidence
-​ Systems-based practice: provide cost-conscious, effective medical care and promote patient safety
-​ Professionalism: demonstrate a commitment to carry out responsibilities. Adhere to ethical principles.
Be sensitive to diverse patient population
-​ Interpersonal and communication skills: demonstrate skills that result in effective communication
exchange. Work effectively with other members of the healthcare team
-​ Use of informatics: use iinformatic to enhance patient care delivery
GOOD PHYSICIAN LEADER
-​ Systems theory and analysis: Identify ways to improve the quality and safety of patient care through
greater care coordination and process improvement
-​ Use of IT: effectively use IT to improve the quality and safety of patient care
-​ Cross-disciplinary training and multidisciplinary teams: understand and respect the skills of other
practitioners
-​ Expanded knowledge: develop greater understanding of population health management, palliative and
end-of-life care, resource management and medical economics, health policy and regulation
-​ Interpersonal and communication skills: further enhance interpersonal and communication skills to
become a true team member. Demonstrate empathy and understanding of cultural economic diversity.
Practice excellent customer service and improve time management

CHANGE MANAGEMENT: Fundamental issues are crucial in the process of convincing physicians to
implement changes. Some of these changes include…
Health care leadership opportunities

Physician success model and how to be a leader

APPLYING SYSTEMS THINKING IN HEALTH CARE
Dr. Sood

What is a need?
A survival, emotional, physical, and metaphysical requirement of a person or population that is not met through
existing solutions of paradigms

Follow a IDEO human-centered design process to learn - build - and measure

The “Patient centered” Ecosystem: How much of the $4T GDP flows into social drivers of health
The Social Determinants of Health (SDoH)
-​ How much of our health care efforts take into account in the overall well-being of a person
-​ 40% determined by socioeconomic factors
-​ 10% determined by physical environments
-​ 30% health behaviors
-​ 20% determined by healthcare and access to care

Public Health Crisis - The US has 4% of the world’s population, but as of 7/16/20, approximately 26% of
its COVID-19 cases and 24% of its COVID-19 deaths
Value-Based Care

CMS definition of Value Based Care: Paying for healthcare services in a manner that directly links performance
on cost, quality, and the patient’s experience of care. Examples include Shared Savings, Capitation, Bundled
Payment, and Global Risk.

What is an ACO?
-​ Accountability Care Organizations are groups of hospitals, providers, and community partners who
come together, along with a health plan, to improve patient outcomes and reduce health care costs by
delivering highly coordinated care.
-​ In an ACO, we will help our patients:
-​ Avoid unnecessary trips to the ER
-​ Address social determinants of health
-​ Better manage medications
-​ Reduce preventable hospital admissions

HABITS OF A SYSTEM THINKING PHYSICIAN * High YIELD

-​ Seeks to understand the big picture
-​ Consider upstream and downstream events
-​ What was added to or removed from a situation
-​ What's the context outside the clinic/hospital
-​ Observe how elements within systems change over time, generating patterns and trends
-​ Policy changes to Medicare and Medicaid
-​ 900B medicaid cuts
-​ Adoption of tech
-​ HITECH act of 2009
-​ Recognizes that the structure of a system generates its behavior
-​ Every process is designed to perfectly achieve the results it gets
-​ Structure and function are interconnected
-​ Identifies the circular nature of complex cause-and-effect relationships
-​ Causal connections and feedback loops
-​ Homeless - overnight ER - discharge - homeless - ER
-​ Intergenerational trauma
-​ Making meaningful connections within and between systems
-​ Innovation can improve but worsen disparities
-​ iWatch EKG’s and other wearable devices
-​ Longevity medicine
-​ Changes perspective to increase understanding
-​ “We see the world not as it is, but as we are.”
-​ Anaïs Nin
-​ The “Empathetic Interview”
-​ Seek to understand the patient journey
-​ Reframe the problem
-​ Surfaces and tests assumptions
 -​ Assuming high health literacy of a patient
-​ Questioning an insurance denial, or pushing back against hospital policy
-​ Considers an issue fully and resists urge to come to a quick conclusion
-​ Provider burnout with # clicks on new EHR system
-​ Solving provider burnout with more training modules
-​ Considers how mental models affect current reality and the future
-​ Considering the perspective of nurses, physicians, janitors, caregivers to understand the context
of patient falls in the hospital
-​ Uses understanding of system structure to identify possible leverage actions
-​ Policy and money drive big change
-​ Medicaid cuts
-​ Startup funding
-​ Considers short-term, and long-term and unintended consequences of actions
-​ Consequences of hospital-wide EPIC rollouts
-​ Impact of COVID-era policies post-pandemic
-​ Recognizes the impact of time delays and exploring cause and effect relationships
-​ Upstream population health interventions
-​ Investments in green spaces, affordable housing, clean air
-​ Pays attention to accumulations and their rates of change
-​ Infectious rates
-​ Underserved communities in need of clinical sites
-​ E.g. covid parking lot clinics
-​ Checks results and changes actions if needed: “successive approximations”
-​ Assess outcomes, iterate to improve, or reconsider
-​ “Fail fast, fail cheap”
-​ Plan-Do-Study-Act
TECHNOLOGY
Dr. Sood