Qualität und Kosten Quality improvement and costs. Dr. med. G. Schüpfer, MBA HSG, PhD

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1 Qualität und Kosten Quality improvement and costs Dr. med. G. Schüpfer, MBA HSG, PhD

2 A wasteful and inefficient industry is in the throes of great disruption Walmart, a giant supermarket chain with many in-store pharmacies, also intends to become one of the leading sellers of affordable health services, says Alex Hurd, its product-development chief.

3 Swiss health care system: Weakness as seen by the federal Government (BAG, 2013) Lack of transparency (Beschränkte Transparenz) Lack of governance (Fehlende gezielte Steuerung) Inadequate statistical data and analytics (Lückenhafte statistische und analytische Grundlagen) Lack of efficiency and avoidable costs caused by wrong incentives (Ineffizienzen und unnötige Kosten durch Fehlanreize) Lack of investments in preventive care (Mangelnde Investition in Vorbeugemassnahmen) Not adequate awareness of insufficient quality (Fehlende Identifikation ungenügender Qualität) BAG Bundesamt für Gesundheit (2013). Die gesundheitspolitischen Prioritäten des Bundesrates-Bericht Gesundheit URL: [ ]. 3

4 'tug of war' the triangle of money quality time(limit) Value (returns)* Quality Customer Provider Price Availability Cost Delivery, allocation** (deadline, quantity) * Nutzen ** Verfügbarkeit

5 the triangle of money quality time to deliver customer value and satisfaction to fulfil service levels and specifications of productsstability of processes (First Pass Yield) quality of process steering quality of processes costs of personnel costs of material overheads / indirect costs (allocated to an object) productivity (value creation per employee) relative costs with reference to benchmark throughput time, cycle time frequency of cycles adherence to schedules time to market/customer

6 Questions What is quality? What are costs? What is the relationship of cost and quality? Is there another scope? Should we discuss cost-effectiveness?

7 Features of hospital services Not tangible products no storage no 1:1 copy invisible no testing no exchange irreversibility after delivery Patient (customer) assurance/ promises/ guaranties of quality trust

8 The service quality concept nach Zeithaml, V. ParasuramanA., Berry L. mouth to mouth Propaganda Personnel requirements real / fictive experiences Gap 1: Perception gap Die Annahmen des Managements bzgl. Service-Vorstellungen stimmen nicht mit den echten Kundenerwartungen/ Anforderungen überein. Kundenforschung notwendig! Customer Expected service Gap 5 Quality of services Service experienced Gap 2: Specification gap Es gelingt nicht, die relevanten Kundenanforderungen in die richtigen Servicespezifikationen (Standards) umzusetzen. Test Validierung der Standards! Provider Gap 1 Gap 2 Service delivered Gap 3 Gap 4 Service-Standards Management expectations Servicepromise Gap 3 Delivery gap Es gelingt nicht, die Servicespezifikationen/Standards zuverlässig und konstant umzusetzen. Voraussetzungen für Einhaltung schaffen! Mitarbeiter motivieren, unterstützen und kontrollieren! Gap 4: Communication gap Es wird direkt oder implizit mehr versprochen, als geboten wird. Einflussnahme auf Erwartungshaltung! Garantiert realistische Versprechen abgeben!

9 Do we start at the wrong end?

10 Just turn it around!

11 Improvement by process management Process management has an internal and external impact External impact improvement of services in the marketplace (relative quality) Potential for improvements up to 30% reductions of process times up to 50% Internal impact cost reductions and higher transparence of costs lower variability of processes up to 15% up to 50%

12 Modern Medicine has a lot of interfaces and needs process management Myocardial infarction: Impact of a certified Chest Pain Unit (Dec. 2013), influence on the Door-to-balloon-time: 8.00% 7.00% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% Mortalität Kardiologie to day: Better identification of type II myocardial infarctions Auditing of the diagnostic processes

13 Tools of process management and mastery of interfaces Hatthorn effect Simple and clear situations: Checklists Complex situations: Guidelines, decision trees, algorithms Crew Resource Management +/- Simulation* Structured programs with different elements Protocols for hand overs, communication training, training of supervisors, focus on sustainability of the management team# Certified centres (CPU, Stroke Unit) Randomised controlled trials Harry C. Sax, MD; Patrick Browne, BMil; Raymond J. Mayewski, MD; Robert J. Panzer, MD; Kathleen C. Hittner, MD; Rebecca L. Burke, RN, MS; Sandra Coletta, MBA: Can Aviation-Based Team Training Elicit Sustainable Behavioral Change? Arch Surg 2009;144(12): Edward H. Livingston: Solutions for Improving Patient Safety. JAMA.2010;303(2): # I-PASS Study Group: Changes in Medical Errors after Implementation of a Handoff ProgramN Engl J Med 2014;371:

14 «time is brain» time to CT : Paramedics have been trained to recognize strokes and warn hospitals in advance, CT machines moved into emergency departments, and drugs pre-mixed to inject directly following a successful scan. Stroke victims arriving with someone were more than twice as likely to be correctly diagnosed by the triage nurse, and had their CT scans performed earlier. Patients eligible for clot-busting medication also received it much faster if accompanied We asked our security team to allow two people to come in with stroke patients rather than just one, he says. And we now consider stroke patients who are coming alone as a group at risk..that ERs provide a friendly stroke liaison to accompany lone patients during the diagnostic and treatment processes. Emergency medicine: Someone to hold your hand - Having a companion can get a stroke victim faster treatment. The Economist; Apr 4th 2015

15 HerzkatheterUntersuchungen/story/

16 Anatomy of a patient till 1960: the immature patient from 1970: the informed patient from 1980: the mature patient from 1990: the patient with autonomy fromb 2000: the competent patient time * G. Nagel, 2005

17 The Patients' Perspective I Radiograph of the author's knees, showing bone-on-bone osteoarthritis of the right knee. Don't kill me (no needless deaths) Do help me, and don't hurt me (no needless pain) Don't make me feel helpless Don't keep me waiting. Don't waste resources, mine or anyone else's by American College of Physicians Berwick D M Ann Intern Med 2005;142:

18 The Patients' Perspective II

19 Clincal and service excellence

20 Categories for quality Surgeon s Satisfaction Satisfaction of patients# Indication Structure (organisation) Processes Outcome Performance #... better tailor the informed consent process to one that meets particular patient concerns and provides more patient-specific care. Acta Anaesthesiologica Scandinavica 2014: Volume 58, Issue 10, pages

21 Sugammadex ist (zu) teuer! Qualität: Das Kriterium der Prozesseffizienz Das Kriterium der Indikationsqualität Vollkosten Teilkostenpersonal erwartete Zeitersparnis Effizienz Vollkosten Anästhesiestunde Fr Fr Vollkosten Anästhesieminute Fr Fr Teilkosten Personal Fr Medikamentenkosten Suggamadex pro ml Fr Verwandte ml 2 ml Kosten Medikation Fr Erwarte Zeitedauer bis zur konventiollen Reversion 60 Minuten X Y Fr Zu erwartende Zeitersparnis Opportunitätsfaktor (1 bis max 2.0) Ersparnis Fr Fr Fr Effizienzgewinn Fr Fr Fr Einleitungszeit Fr SNZ Ausleitungszeit konventionell Fr Ausleitgungszeit mit Suggamadex Datenreihen1 Prozesseffizienz ANZ/SNZ ohne Fr ANZ/SNZ mit Fr Fr Fr Effizienz Effizienz

22 Sugammdex is to expensive?! Additional effects on quality Improved surgeon s satisfaction better conditions to perform the procedure: laparoscopic and bariatric procedures 3 minimal invasive prosthesis surgery of the hips Better outcome quality and patient satisfaction less pain after bariatric surgery 1 less nausea faster street readiness more efficient processes 2 bariatric surgery 1 Surg Laparosc Endosc Percutan Tech 2014; 00; Obes Surg 2013; 23: Acta Anaesthesiologica Scandinavica 2015 Volume 59, Issue 4, pages 441 Acta Anaesthesiologica Scandinavica 2015 Volume 59, Issue 1, pages 1 16

23 Value chain analysis Goal: Identification of cost drivers to improve cost management and determination of the competitive situation 100% der Kosten Kapitalbedingte Kosten Anlagen-Amortisation Kosten d. Umlaufvermögens Versicherungskosten value added profit sales Personalbedingte Kosten Löhne Gehälter Sozialleistungen Unterstützende Wertschöpfungsaktivitäten Beschaffte Güter und Leistungen Primäre Wertschöpfungsaktivitäten Kunde cost driver: multiplicity Cost driver: Lack of standardisation Cost driver: capacity management

24 Experience curve Kosten / je Menge Mit jeder Verdoppelung der kumulierten Mengen entsteht ein Kostensenkungspotential von % der Kosten der Wertschöpfung zu konstanten Preisen. 4 2 bei 20 % Rückgang bei 30 % Rückgang Kumulierte Menge (Erfahrung)

25 Activity is not equal to value True addition of value Useless for core service as required economically wise sustainable and holistic Nursing Activities Unnecessary work Clarifying Waiting time Activities improving quality of care Process- Teams no value added Standards Professionalism Working environment Organisation Qualification

26 Strategies to improve efficiency in hospitals The Japanese concept: Elimination of three «M s» MUDA = activities not value adding MUDA = nicht-wertschöpfende Tätigkeiten MURI = Overload for people and equipment MURA MURI = Variability = Überlastung and multiplicity von of Mensch processes und result in volatility Maschine MURA = Unregelmässigkeiten infolge Ask 4 questions Schwankungen to identify in Diagnose/Therapieplanung M: bzw. Diagnose-Therapievolumen a) What is hindering me to do my job/work properly? b) Is a certain activity adding value for the patient? c) Does a certain activity assure value for patients? d) What happens if a certain activity is omitted?

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28 Gools of a clinical integrated information system (EMR) Enterprise Increasing productivity Patients best possible quality Employees more time for patients, less time for administration 37

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30 Paper free: Any Where, Any Time with Any Device Goal All information is available anytime, complete in a timeline manner anytime in dependant of the device used a digital infrastructure is needed to overcome knowledge fragmentation in the cure and care chain. Cooperation with referring physicians and patients as partners e-medication Electronic platform for communication Electronic support of decisions Automatisation Speech recognition 39

31 Management of hospitals in the age of DRG s Mastering LOS Pathways, same day surgery Improving after care (geriatry, rehabilitation etc.) OR Management is capacity management ICU Management: Focus on quality Emergency Room Management: Focus on speed and diagnostic accuracy Assessment of support processes Avoid waste

32 Cost types accounting Case based Cost Accounting Total costs Indirect costs true indirect costs «indirect costs» Direct costs Cost Center accounting Indirect costs ILV Proportional costs Process cost calculations pricing cost drivers Main processes Subprocesses Cost objects accounting Direct costs costs per process calculated proportional cost X quantity structure of costs Standard costs

33 Association of Hospital Spending Intensity with Mortality and Readmission Rates in Ontario Hospitals JAMA. 2012;307(10): doi: /jama

34 Quality leaders are cost leaders are Masters of the experience curve Process management leads to lower costs due to less avoidance and correction costs for failures The better compensations for complications in the Swiss DRG system is probably not helpful to improve quality of care.

35 Qualität und Kosten Spannungsfeld zwischen operativen und strategischen Leistungsreserven aus dem Blickfeld des Wertsteigerungsmanagements

36 Summary I: thinking is essential before placing a screw anchor - «Grübeln bevor dübeln» Consider cost and quality together and be aware of the triangle The definition of quality of anaesthesia is open Accept patient and surgeon s satisfaction as important quality criteria. Quality leaders in every industry are cost leaders, because of mastering interfaces and processes

37 Summary II: thinking is essential before placing a screw anchor - «Grübeln bevor dübeln» In the health care industry there is room for improvement in process management, it will lower costs and improve quality. But Investments in IT and competencies of staff are required. Medical and economical ethics are not contra dictionary but complementary: do the right things in the right way!

38 Danke für die Aufmerksamkeit! Kontakt: Disclaimer: Der Referent vertritt ausschliesslich seine persönliche Meinung im Rahmen seiner verfassungsmässigen Grundrechte. Seine Aussagen sind weder mit seinem Arbeitgeber abgestimmt noch von diesem genehmigt.