Finding Value in Health Care’s : Our Escape Fire…..

Experts believe that a stunning 20 to 40 percent of the $2.4 trillion America spends on health care in 2008 will be wasted

on misuse (including harmful and fatal errors),

overuse (care that’s unnecessary)

or underuse ( effective care that’s not provided).

The Overuse and Misuse of Health Care Resources: Reduction of Bronchodilator Utilization in the Management of Acute Bronchiolitis in Children

Finding Value in Health Care’s : Our Escape Fire…..

The Five Domains of Value: Access Technical Quality Functional Status Service Satisfaction Cost/price

Value (V) == A + TQ +FS + SS

C

Core Conclusions of the IOM Report..

Every system is perfectlydesigned to achieve exactlythe results it gets.

The problems come from poor systems…not badpeople

Redesign Care Based on Best Practices

Use Information Technology to Improve Access to Information and to Support Clinical Decision Making

Develop Effective Teams

Coordinate Care Among Services and Settings

Measure Performance and Outcomes

Changing the System…..

Bronchiolitis

A self-limited condition; viral mediated associated with URI symptoms, cough, and wheezing; most commonly dx age <2.

#1 discharge ICD-9 diagnosis, excluding birth

#2 in aggregate costs

incredible degree of variation

New evidence-based AAP guidelines

The Evidence From the American Academy of Pediatrics…“Bronchodilators should not be used

routinely for management. An optional trial of an - or ß-agonist should be continued only if objective evaluation indicates a clinical response. Most positive studies of bronchodilators for management of bronchiolitis show transient improvement of unclear clinical significance.”

Specific AIM:To reduce the utilization of bronchodilators for bronchiolitis by 20% when comparing 1st Q2010 data to 4th Q 2008 and 1st Q 2009 data in the Pediatric Inpatient Ward and in the Pediatric Emergency Room

Global Aims:To Improve Effectiveness of Care (IOM)

Timeline

Plan……Create the Team

Clinical Physicians: Pediatric Hospitalists; Pediatric ED Physicians, Community Pediatricians, and Pediatric Pulmonologists

Respiratory TherapistsNurse Managers from the Inpatient and Pediatric EDPhysician Liaison to IS Department (order set creation)

Plan….

POLICY

Measurement

People

Misuse andOveruse of

Bronchodilators

No HospitalPolicy to allowRT to use MD

protocol

No streamlined process tocreate an orderset

No Hospital Policy Requiring MD to use protocols

MDs dont know evidence

Parents want treatment

MDs dont like "protocols"

Barriers to Implementation: A Fishbone Diagram

Inpatient Data will need to be based on Billiing Data

)

Respiratory Rate 0 (normal) 1 (infant>50; child >40, adolescent>20)

Accessory Muscles

0 (normal) 1 (supra/sub/inter costal retractions

2 (neck/abdominal muscles)

Air Exchange 0 (normal) 1 (localized decrease)

2 (diffuse decreased)

Wheeze 0 (none/end-exp) 1 (entire expiration)

2 (entire expiration/inspiration)

I: E Ratio 0 (less than 1:2) 1 (greater than 1:3)  

Do: The Intervention An Objective Respiratory Acuity Scoring Tool

Do: The Intervention

Do: The InterventionA Standardized Bronchiolitis Order Setin ED and Inpatient settings

IF Score is 4 or greater—trial of Racemic Epinephrine (evidence demonstrates some modest improvement in Resp Score—so will wait for scores to be clearly indicative of respiratory distress)

IF one wants an Albuterol Trial ( should be based on primary FH of Atopy/Asthma)—must specify “Asthma Protocol with albuterol” (and albuterol will be given after a post suction score of 4)

There will be 2 orders on the Bronchiolitis Order Set

Bronchiolitis Protocol (start with Racemic Epinephrine)

Bronchiolitis Protocol (start with Albuterol)

Bronchiolitis Protocol

•Monday, October 12, 2009 @ 10:30am - 11:00am in the PEDS Conference Room

•Wednesday, October 14, 2009 @ 7am - 7:30am in the Playroom

Do: The Intervention– Education and Changing Culture

Check

ACT

LESSONS LEARNED NEXT STEPS “Every system is perfectly designed

to get the results it gets. If we want different results, we must change the system”

“Culture eats strategy for lunch.”

“Effective leaders help others to understand the necessity of change and to accept a common vision of the desired outcome”

Monitor Control Charts for next 3 months to ensure stable process

Sustaining Change

Integrate in to Physician Report Cards

Development of a Balanced Score

EBM Lunch Series (CME)

Closing the Gap……