1. PA 574: Health Systems Organization Session 3 – April 17, 2013

2.  Intrinsic Goals: Relatively independent of other goals More is always better Hard to find  Instrumental Goals: Often interdependent with other goals More not always better Indirect to “desired” goal Common but numerous and imperfect

3.  Struggle to find simple, informative system goals  Striving for single, intrinsic goal measure has led to important realizations and goal/measurement thinking (WHO, etc.)  Recognition that a set of instrumental goals related to “true” goal is likely best  Some of the points along the way….

4.  Six Aims  Safe  Effective  Patient-centered  Timely  Efficient  Equitable  Ten Rules for System Redesign…

5. 1. Care is based on continuous healing relationships; 2. Care is customized according to patient needs/values; 3. The patient is the source of control; 4. Knowledge is shared and information flows freely; 5. Decision making is evidence-based; 6. Safety is a system property; 7. Transparency is necessary; 8. Needs are anticipated; 9. Waste is continuously decreased; and, 10. Cooperation among clinicians is a priority.

6.  Note: All three are instrumental…  Access: Availability Opportunity Knowledge (e.g. health literacy)?  Quality: Better health related outcomes? Other things e.g. convenience? From who’s perspective?  Cost: Yes..but is this perhaps the most instrumental…

7.  Three intrinsic goals…  Population Health Yes..but overall, in distribution..that easy..  Fairness in Financial Contribution Macro issue about how resources collected Does this speak to level of expenditure?  Responsiveness to People’s Expectations in Regards to non-Health Related Matters Multi-dimensional Culturally divergent? Why non-health?

8.  Where we are now….  Goals:  Improving the experience of care  Improving the health of populations  Reducing per capita costs of health care  Preconditions:  “Enrollment” of population  Commitment to universality  Role of “integrator”

9.  Intrinsic or instrumental??  Leave out some high macro concerns e.g. fairness of contribution???  Can be acted on globally and locally – perhaps a key element..  Basis of most “new” system and care transformation – Primary care homes, Accountable care organizations, etc..

10.  Partner with individuals/families  Redesign of primary care  Population health management  Financial Management  System integration at macro level

11.  Level 1: Patient and Community Experience of patients  Level 2: Microsystem Functioning of small units of care delivery  Level 3: Organization Functioning of organizations that house microsystems  Level 4: Environment Policy, payment, regulation, accreditation Shapes behavior, interests and opportunities of Level 3 organizations

12.  Donabedian: Structure,Process,Outcome  Structural measures easiest – how much stuff do we have  Process Next – what did we do  Outcome Best but Hardest – first two are instrumental Striving to get here…

13.  Population Health: Disability or quality adjusted life years (DALYs/QUALYs) Amenable Mortality Distribution of health states e.g. percentage of population considered obese Process measures (health as “quality”):  NCQA/HEDIS process measures  Ambulatory Care Sensitive Admissions  All Cause Re-admission

14.  Experience of Care Consumer Satisfaction (?) Timeliness Safety Cultural Competence Patient-centeredness  Reducing Per Capita Costs Population level – note this needs “population”

15.  Well lets look at some international comparative measurements…..