1. 2003: Improvements and Other Changes Francois de Brantes May, 2003 Founded by The Business Roundtable Supported by the Robert Wood Johnson Foundation

2. To Err Is Human: Building a Safer Health System n Institute of Medicine n Committee on Quality of Health Care in America

3. Anesthesia During Surgery   44,000 - 98,000 Preventable Hospital Deaths (IOM) The Quality Imperative 1,000,000 100,000 10,000 1,000 100 10 1 DPMO 123456123456 © 1994 Dr. Mikel J. Harry - V4.0 SIGMA 93% good 99.4% good 99.98% good Low Back Treatment Overuse Mammography Screening Underuse Post Heart Attack Medications Underuse Antibiotic Overuse    

4. LOWHIGH LOW Effectiveness of Care Efficiency Breaking The Status Quo Provider Universe Today Provider Universe Tomorrow

5. Removing The Barriers To Change n Meaningful Measures n Engage Consumers n Engage Hospitals

6. Three Leaps – 1st Generation n An Rx for Rx –Computer Physician Order Entry (CPOE) –85% serious drug errors prevented –Net cost savings n Practice Makes Perfect –Evidence-based Hospital Referral (EHR) –> 20% mortality reduction for 7 complex treatments n Sick People Need Special Care –ICU Daytime Staffing with CCM Trained M.D. –> 10% mortality reduction –Net cost savings

7. Leap Refinements FROMTO CPOE Implementation targets 2004/20052005/2006 IPS Implementation targets 2002/20032004/2005 IPS Telemedicine In developmentAllowed Strong emphasis on integrated Information Systems

8. Leap Refinements – EHR FROMTO CABG500 per year550 for last 12 mos or as annual avg over 24 mos PCICoronary Angioplasty All PCIs, 400 for last 12 mos or as annual avg over 24 mos AAA repair30 per year50 for last 12 mos or as annual avg over 24 mos Carotid Endarterectomy 100 per yearEliminated Esophageal cancer surgery 7 per year8 for last 12 mos or as annual avg over 24 mos Pancreatic cancer surgery Not measured6 for last 12 mos or as annual avg over 24 mos R/A State-reported outcomes not allowed for VA

9. Leap Refinements – Process n Revised survey ready n All hospitals asked to re-submit in Q2 n New results posted in Q3 & Q4 n Same process on-going

10. Leapfrog “2 + 6” NQF Group 1 ~ “ORYX” 31 NQF Group 2 8 Measures – Beyond Leapfrog 5 44 Unique Measures: 8 outcomes – infections or r/a mortality 6 volumes – number of procedures or patients 3 structural processes – CPOE, ICU, discharge plans 27 clinical indicators – medication admin, interventions + a number of other structural safe practices measures to create a comprehensive overview of hospital performance. CMS/AHA “Pilot 10” UCSF/ AHRQ “Top 11”

11. Engage Consumers n Heart NEJM 12-12-2002 –NEJM survey results –FACCT Toolkit

12. Engage Consumers n Heart –FACCT Toolkit –NEJM survey results n Mind –Web Hits Subimo DQ SQC Health Grades 2002

13. Engage Consumers n Heart –FACCT Toolkit –NEJM survey results n Mind –Web Hits n Wallet –Co-pays, co-insurance, PBAs

14. Engaging Hospitals n Mind –Thousands of press hits –Letters from plans Almost 60% of hospitals in targeted regions fill out survey…30% of all targeted Hospitals

15. Engaging Hospitals n Mind –Thousands of press hits –Letters from plans n Wallet –Direct –Indirect

16. Making The Business Case n Determine impact of mechanisms to close net shortfall: –Direct $$ –Intensivist reimbursement –Bonus payments (e.g. x + x%) –Award –Volume shift –Indirect $$ –Cost of capital –Reduced liability/malpractice premiums Pilots underway now…mo re to come!

17. Measuring Results Missing Appropriate Leaps per Patient (n) per Hospital Stay Appropriate Leaps per Patient (n) per Hospital Stay Σ Σ n n = % Defects “all missing” for non-reporting hospitals Counting down to Zero Make all accountable: plans, purchasers, providers, and patients

18. Reducing Avoidable Deaths LeapCPOECABGAngioAAAEndartEsophNICUIPS Observations28,324307425301222802,405 Defects27,13414510015771391,881 Leap-specific Defect Rate 95.80%47.20%23.50%50.00%63.10%50.00%48.80%78.20% Differential Risk (deaths) per 1000 Defects 0.292.8251.499.143.318 Avoidable Deaths Full Adoption5.72.81.20.80.2 3.543.3 Remaining5.41.30.30.40.1 1.733.9 Weighted Defect Rate 57.5 43.1 75.00% Totals Avoidable Deaths – full adoption Avoidable Deaths – remaining Modify and refine model to reflect Leap changes … and continue the countdown to zero.

19. That’s one small step for all of us, one giant leap for patient safety.