National Symposium

Risk Management and Problem Solving

for Quality Hospitals
as an Instrument to Ensure
Hospital Profitability in the JKN Era

Jakarta, Indonesia
May 18, 2017

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 A full-service, not-for-profit medical care and research institute
focused on renal disease, diabetes, hypertension, lipid disorders,
cardiovascular disease, cancer,
and sepsis located in New York City
(a “hospital” under New York State law, Article 28)

Early chronic kidney disease (CKD)

through end-stage disease (ESRD), including all forms of dialysis and
living and deceased donor organ kidney transplantation

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 The Rogosin Institute:
550 people serving NYC
• Non-profit kidney care provider in
NYC
• Affiliated w/ NewYork-Presbyterian
Health System/Weill Cornell Medicine
• 8 dialysis units in Brooklyn,
Manhattan, and Queens
• CKD clinic and clinical research
• Kidney transplant program
• Center for Health Action and Policy:
• Dreyfus Health Foundation now
part of CHAP
 Closely affiliated with:

NewYork Presbyterian Hospital

ranked 6th in U..S.A, and 1st in New York
City
5 primary campuses
1,800 beds
plus
30 linked hospitals and/or special clinics
in the Network

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Prevention Research
Central Brooklyn Clinical, Basic
Health Movement Renal Aid
Mississippi Immunology
China T cell reg
Lipids/sepsis
Cancer, Diabetes

Early Diagnosis
Screening
Patient Care Policy
PCP CKD Symposia
Partnerships Roundtables
ESRD White House
Congress
Improved CDC
Implementing ESCO;
transition to Developing new CKD New Models
Transplantation, models NKCA
Dialysis CMS/CMMI KCC, KCP

Public
OUTREACH Professional

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 Hebrew Home (PD)
Manhattan East and West
Methodist Home

Integrated ESRD Care

Woodside
Auburndale

Lower Manhattan Hospital

Methodist Hospital
McDonald Ave (South)
Linden Blvd (East)
Brookdale
Dean St.
PD unit
Sunset Park
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 Policy
and Policy
U.S.A. INDONESIA
Affordable Care Act JKN
American Health Care Act
Access Unique problems of multi-island
Coverage nation
Pre-Existing Conditions Access –
Problem of Complex chronic illness Coverage – basic for all 133
Value-Based Purchasing million - BPJS
MIPS Non-discriminatory re condition
MACRA Communication
Alternative Payment Models Quality as an issue; variability
Collaborative Care vs Integrated Care

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 Center for Health Action and
Policy
Goal: To be a premier center for the discussion of key issues in health and health care with
an emphasis on chronic illness and renal disease and its multiple co-morbidities;
Policy Formation and COLLECTIVE ACTION!
• Symposia
• Roundtables (Health Literacy, Mental Health, Nutrition, Transplant)
• Kidney Health Trainings (for patients, caregivers, and community leaders)
• Transplant Workshops
• Problem Solving for Better Health® (PSBH®)
• Collaborative CKD project with Shanghai PSBH/N colleagues
• Patient interviews and focus groups
• Cultivating strong partnerships with our patients, local communities, and critically important
organizations and peoples
Together we can prevent and/or slow the progression of chronic
kidney disease and improve the healthcare delivery system
 Dreyfus Health Foundation

PSBH® programs in 32 countries since 1989

PSBH at the heart of Rogosin’s programs in
New York City and beyond

Sample programs:
• Nursing in China; !4,000 nurses currently involved
• Brazil: 120 favelas (slums) lined as network of healthy communities
• Mississippi Delta: Basic healthcare/nutrition/education/jobs/nursing
• INDONESIA: PSQH
The Center of All the We Do:

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Quality and Risk Management
• With patients first in all that we do,
QUALITY and SAFETY must be our
mandate.

• However, it is also essential to making

the hospital function successfully in
meeting local and national regulatory
requirements and as a cost-effective
business.

• Hospitals cannot lose money!!!

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Importance of Quality and Safety in USA
 Enhancement of Quality & Patient Safety (QPS)
 Critical to Our Mission
 Core Hospital Value
 Unifying Principle for Board, Clinical, and
Administrative Leadership
 Critical to Protecting the “Brand” of Rogosin or
the NewYork-Presbyterian Regional Hospital
Network
 Institutional Differentiator
 Important Component of Performance-Based
Reimbursement – outcomes-based and no longer
fee for service in the USA

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How to Measure Hospital “Quality”

• Services available
• Morbidity
• Mortality
• Complication rates
• Infection rate – surgical, general
• Length of stay
• Readmission rate
• Return to functional status
• Return to work

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 NYP RHN Safety/Quality Data
Preventable Harm
Index =

Infections:
• CAUTI
NYPRHN - Preventable Harm Totals - Quarterly Trends
• CLABSI
• C. difficile
140

Patient Safety
120
Indicators
100
• US News PSI
• Post-op DVT/PE
80
NYP/Lawrence
NYP/HV
• Hospital-acquired
NYP/Queens
NY Methodist
pressure ulcers
60

Never Events:
40 • Misadministration
of radiation therapy
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• Falls with serious
injury or death
0
Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 • Retained foreign
object
• Wrong-site or
wrong-patient
surgery

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 Wrong-Side Surgery
“…every other day in Pennsylvania health
care facilities an actual adverse event or
near miss of a wrong-site surgery
occurs.”

Pennsylvania Patient Safety

Authority, June 2007

 69% wrong side surgeries

 14% wrong body part
 9% wrong procedure
 8% wrong patient
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 Top 10 General Surgery Errors in New York
State by Volume
(85% of total surgical errors)

• Unplanned operations or re-operations - related to primary procedure

within 90 days
• Post-op wound infections (30 days)
• Hemorrhage or hematoma - requiring drainage, evacuation
or other intervention
• Death
• Deep Vein Thrombosis (new and documented)
• Anastomotic leakage (requiring repair)
• Wound dehiscence (requiring repair)
• Pneuomthorax (regardless of site or treatment
• AMI (unrelated to a cardiac procedure)
• Acute pulmonary embolus (new, confirmed or suspected and treated

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General Safety/Quality Issues
• Reduce Health Care–Associated Infections
• Improve Patient Verification
• Conduct Time Outs Before Procedures
• Enhance Caregiver Communication
• Improve Medication Safety
• Practice Medication Reconciliation
• Reduce Patient Falls
• Encourage Patient Participation in Care
• Identify Safety Risks
• Respond to Patient Condition Changes

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 The NYP Regional Hospital
System Quality Approach
Commitment
Re-Energized Structure & Processes

Worked Closely with Clinicians

Launched Key Initiatives

Solidified Quality / Operations Partnership

Began to Foster Ownership by All

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Hospital Quality Structure

Quality  Set NYP Quality Strategy

Council  Prioritize Initiatives

Quality  Facilitate Front-Line Implementation

Operations  Monitor Performance
Committee

Risk  Identify High-Risk Activities

Mitigation
 Analyze Data & Monitor
Committee
Performance

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 A New Element
Patient Satisfaction
and
Consumer Assessment
of
Healthcare Provider Services
(CAHPS)

Now part of government rating of quality

and
reimbursement payment
for services provided
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Weighted Averages in Patient Reports

Excerpt from Standard Press

Ganey Report

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A Problem with Weighted Averages

Scenario 1 2 3 4 5 Press Ganey

(Very Poor) (Poor) (Fair) (Good) (Very Good) Weighted
Average

A
(20 total responses)
20 50%

B
(20 total responses)
10 10 50%

C
(20 total responses)
10 10 50%

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 Five-Star Rating System

• Hospitals
• Nursing Homes
• Dialysis Clinics
• Physicians

Bell Curve vs. Fixed Bell Curve?

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 The Question

What can we do to improve

hospital quality and control
costs?

We are still not where we want to be!!!

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 The Modern Hospital
The modern hospital as a complex,
multilayered entity:
Patients
Physicians/Surgeons
(may be highly specialized)
Nurse Practitioners
Nurses
Aides
Janitorial/Maintenance Staff
Administrative
Clerical,
Billing…...
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 A TOOL for Quality Hospitals

Problem Solving for Better Health

(PSBH)

Problem Solving for Better Hospitals

PSBHosp

Problem Solving for Quality Hospitals

PSQH

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 Problem Solving for Better
Health
• PSBH Methodology
1. Defining the problem
2. Prioritizing the problem
3. Defining a solution/Asking the “Good Question”
4. Creating an action plan
5. Taking action

Participants apply the PSBH methodology to

solve local public health problems
PSBH (PSQH) and The Hospital
The Hospital as a Community
The Program:

• A series of PSQH Workshop, each involving a cross-

section of the hospital community

• Goals: Define the problems

Prioritize
Develop solutions: Ask a Good Question!!
Prepare an Action Plan
Implement the Plan
Evaluate degree of success or failure
Renew the process

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Summary of the PSQH Process
Much Better
Continuous quality improvement Hospital (PSQH)
New
Problem
Evaluation
ACTION

Plan of Action
Possible
solutions

Priorities
Problems Re-attack the
same problem
Good Hospital

Individual responsibilty – Overall team effort

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 Key Points

• Use available resources: people and

physical resources
• Make no excuses – just get it done!!
• Create transformational leaders at all
levels
• Create an iterative, self-sustaining
and auto-replicating process

• A LEARNING HEALTH SYSTEM

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 Factors Influencing Health:
Health as a Product of Society
Food
Comorbidities
Finances
Age Culture Housing

Spiritual Beliefs

Education Family

PATIENT
Depression

Transportation Psychological
Factors
Political Climate
Health Care System
Stress
Anxiety
Confidential 32
Confidential
Local Partnerships/Competition -
Brooklyn

NYC Health & Hospitals Corp

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 Integrating ESRD and CKD
•Education
•Health Promotion
•Disease Prevention
•Screening
•Early Detection
•Improved CKD Management
•Prep for ESRD
•Integrated ESRD Care
• Restoration of kidney function:
Dialysis, Transplant; Build new
kidneys
The Continuum of Health and Disease
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Rogosin as Much More than a
Dialysis/ESRD Care Provider
Dialysis Clinics without Walls
Concept:
Community better-health resource
Focal point for community engagement, activation

Greenberg Center for Integrative Healthcare

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Confidential
Confidential 38
 Local Partnerships

The Central Brooklyn Health Movement

Brookdale Hospital
Brownsville Multi-Service Family Center (PCP)
CAMBA
NYCDOHMH
Borough President’s Office
Borough Churches, Synagogues, Mosques
>20 Businesses, Schools, Recreation Centers, Social Clubs,
Sports, Transportation
HealthFirst
CMMI Accountable Health Communities Grant
Award Announcement Spring 2017
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Confidential 40
The Hospital as Central in Health and Healthcare
Delivery

Creates positive community

atmosphere – mutual help
Food
Comorbidities
Finances
Age Culture Housing

Spiritual Beliefs

Education Family
HOSPITAL,
PATIENT

Transportation
Psychological
Factors
Political Climate
Health Care System
Primary Care, Stress
Social Anxiety
Specialists
Services
Agencies.Payment
Govt, Private
Insurance 41
 Only Goal:

Continuous Quality
Improvement
to be
THE BEST OF THE
BEST

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Terima Kasih
Banyak!!