Barach talk.MAB.Final
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This document discusses the potential role of national health insurance in creating a safe, affordable, and high-quality healthcare system in the Bahamas. It begins by outlining the government's vision of transforming healthcare to be the safest and most effective in the region. It then discusses some of the current challenges in the Bahamian healthcare system, including a lack of coordination, increasing costs, and workforce issues. The document also reviews international healthcare system rankings and compares mortality rates between public and private patients in Bahamian hospitals. Overall, the document examines how a national health insurance system could help address issues in the current healthcare system and better serve the needs of Bahamians.
![• “…the very first requirement in a Hospital [is] that it
• should do the sick no harm.”
• – Notes on Hospitals, 1863
Florence Nightingale
It is all about the patient!](https://image.slidesharecdn.com/c45827bd-93f7-45e2-ab31-e99de345c3db-150913052518-lva1-app6892/85/Barach-talk-MAB-Final-8-320.jpg)
Barach talk.MAB.Final
- 1. The Role of National Health Insurance in creating Safe, Affordable, and High Quality Outcomes for Bahamians? Paul Barach, MD, MPH March 5, 2015 Medical Association of the Bahamas
- 2. NHI: Key System Drivers Health SocialEconomic Patient Politics, regulations and agencies 2
- 3. Vision of NHI • The Government of The Bahamas is committed to transforming the healthcare systems into the safest, most effective and most compassionate provider of healthcare in the region.
- 6. Mortality rates in PMH vary for public and private patients 263 deaths/ 1781 admis 17 deaths 248 admis 270 deaths 9867 admis 6 deaths 1171 admis15 deaths 2120 admis 0 deaths 44 admis
- 7. • Lack of coordination, with providers in silos, fragmented service models • Increasing Patient Expectations • Lack of active follow-up to ensure the best outcomes • Patients inadequately trained to manage their illnesses • Large variation in outcomes for patients • Very costly, unsustainable financial costs • Severe workforce issues • Lack of transparency of Outcomes and Scores • Discouraged, Unhappy Workforce Bahamian Healthcare is challenged by:
- 8. • “…the very first requirement in a Hospital [is] that it • should do the sick no harm.” • – Notes on Hospitals, 1863 Florence Nightingale It is all about the patient!
- 9. Politics and medicine “Medicine is a social science and medicine is nothing but poli4cs on a grand scale” Rudolf Virchow, (1821-‐1902) Prussian physician, one of the originators of the cell theory, worked out the mechanism of pulmonary thromboembolism, wri4ng about the 1848 typhus epidemic in Upper Silesia
- 10. AUS CAN FRA GER NETH NZ NOR SWE SWIZ UK US OVERALL RANKING (2013) 4 10 9 5 5 7 7 3 2 1 11 Quality Care 2 9 8 7 5 4 11 10 3 1 5 Effective Care 4 7 9 6 5 2 11 10 8 1 3 Safe Care 3 10 2 6 7 9 11 5 4 1 7 Coordinated Care 4 8 9 10 5 2 7 11 3 1 6 Patient-Centered Care 5 8 10 7 3 6 11 9 2 1 4 Access 8 9 11 2 4 7 6 4 2 1 9 Cost-Related Problem 9 5 10 4 8 6 3 1 7 1 11 Timeliness of Care 6 11 10 4 2 7 8 9 1 3 5 Efficiency 4 10 8 9 7 3 4 2 6 1 11 Equity 5 9 7 4 8 10 6 1 2 2 11 Healthy Lives 4 8 1 7 5 9 6 2 3 10 11 Health Expenditures/Capita, 2011** $3,800 $4,522 $4,118 $4,495 $5,099 $3,182 $5,669 $3,925 $5,643 $3,405 $8,508 COUNTRY RANKINGS Top 2* Middle Bottom 2* EXHIBIT ES-1. OVERALL RANKING Notes: * Includes ties. ** Expenditures shown in $US PPP (purchasing power parity); Australian $ data are from 2010. Source: Calculated by The Commonwealth Fund based on 2011 International Health Policy Survey of Sicker Adults; 2012 International Health Policy Survey of Primary Care Physicians; 2013 International Health Policy Survey; Commonwealth Fund National Scorecard 2011; World Health Organization; and Organization for Economic Cooperation and Development, OECD Health Data, 2013 (Paris: OECD, Nov. 2013). Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally
- 11. Operations performed on Fridays were associated with a higher 30-day mortality rate than those performed on Mondays through Wednesdays: 2.94% vs. 2.18%; Odds ratio, 1.36; 95% CI, 1.24–1.49)
- 12. No system beyond this point 10-2 10-3 10-4 10-5 10-6 Civil Aviation Nuclear Industry Railways Chartered Flight Drilling Industry Chemical Industry (total) Fatal risk Anesthesiology ASA1 Innovative medicine (grafts, oncology …) ICU Trauma centers Very unsafe Ultra safe Professional fishing Unsafe Safe Hymalaya mountaineering Combat A/C, war time Medical risk (total) Scheduled surgery Chronic care Radiotherapy, Biology Blood transfusion Finance Fire Fighting Food Industry Processing Industry Amalberti R. et al.: 5 System barriers to achieving ultra-safe health care. Ann Intern Med. 2005;142:756-764. Average Rate per Exposure of Catastrophes and Associated Deaths in Various Industries and Human Activities
- 13. Assuming a system is 99.9% safe; How Safe is “Safe Enough” for surgery??? • 84 unsafe landings /day • 1 major plane crash every 3 days • 16,000 mail items lost/hr • 37,000 bank transaction errors/hr
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- 15. 15
- 16. IGNAZ SEMMELWEIS – USE OF CHLORINATED LIME HAND WASHING FOR PREVENTION OF PUERPERAL FEVER (THE MIDWIVES’ WARD LOWER THAN DOCTORS’)
- 17. Semmelweis – the mortality rate in April 1847 was 18%; after hand washing was instituted in mid-May, the rate in July was 1%
- 18. DR IGNAZ SEMMELWEIS’S FATE Semmelweis was outraged by the indifference of the medical profession to pa4ent suffering and death ... His contemporaries, including his wife, believed he was losing his mind, and in 1865 he was commiPed to an asylum.. He died there of sep4caemia only 14 days later, possibly from the result of being severely beaten by guards
- 19. HH: hand hygiene. OT: operating theatre. NSG: non-sterile gloves. SG: sterile gloves Annelot C Krediet, et al. Hygiene Practices in the Operating Theatre: An Observational Study., BJA, 2011
- 20. Normalized Deviance • By a deviant organizational behavior, we refer to “an event, activity or circumstance, occurring in and/or produced by a formal organization, that deviates from both formal design goals and normative standards or expectations, either in the fact of its occurrence or in its consequences.” • Once a community normalizes a deviant organizational practice, it is no longer viewed as an aberrant act that elicits an exceptional response; instead, it becomes a routine activity that is commonly anticipated and frequently used. Diane Vaughan, 1999: 273. ; Barach, Phelps 2013
- 21. How does it start? • The normalization literature distinguishes between factors that lead to the genesis of organizational deviance and factors that cause deviance to become routine, rather than idiosyncratic, behavior. • A permissive ethical climate, an emphasis on financial goals at all costs, and an opportunity to act amorally or immorally, all contribute to managerial decisions to initiate deviance.
- 22. NHI- Donabedian Causal Chain Lilford R J et al. BMJ 2010;341:bmj.c4413
- 23. “If an error is possible, someone will make it. The designer must assume that all possible errors will occur and design so as to minimize the chance of the error in the first place, or its effects once it gets made” Norman, The Design of Everyday Things, 2001
- 24. Slide: 24 The 93% vs. 7% Rule Organizational Design 93% Knowing Violations Human Error (People) Reckless Conduct (People) Negligent Conduct (People) (People)
- 25. Reason – Complex Systems
- 26. TeamSTEPPS--Model of Multi- disciplinary Care Teamwork Mutual Trust Shared Mental Models Closed Loop Communication Team Leadership Team Orientation Back-Up Behavior Adaptability THE CORE Baker, D, Salas E, Barach P, 2006, 2007 Mutual Performance Monitoring
- 27. Four building blocks towards towards a “high reliability” healthcare organization The definition of a high reliability organization extends beyond patient safety to encompass quality care – and ultimately value. ‘High reliability’ organizations: 27 After Berg M and KPMG Report
- 29. Stages in the development of a safety culture CALCULATIVE We have systems in place to manage all hazards PROACTIVE Safety leadership and values drive continuous improvement REACTIVE Safety is important, we do a lot every time we have an accident PATHOLOGICAL Who cares as long as we're not caught GENERATIVE (High Reliability Orgs) HSE is how we do business round here After Ron Westrum
- 30. The Five Dysfunctions of Teams After Patrick Lencioni, 2007 30 Absence of trust Fear of Conflict Commitment Accountability Results
- 31. PopulaIon Health Management System of Care
- 32. Benefits Package Building Health needs (BOD) Required Health Interventions
- 33. Criteria Results Group 1: Dr. Charles Group 2: Dr. Weech Group 3: Dr. Neymour 1 Safety Essential Effective / efficacy / Cost-efficiency 2 Burden of disease Effective / efficacy Value-added 3 Essential BoD BoD 4 Cost efficiency Value-added Culture / Language 5 Efficacy Efficient / cost effective Essential 6 Resource Impact on Health System Safety Resource Impact 7 Value added Resource impact Safety 8 9 ?Education / Prevention
- 34. Benefits Package Building Health needs (BOD) Required Health Interventions Criteria Definition Inclusion/exclusion Benefits Package Draft
- 35. Benefits Package Building Guidelines and Protocols Quality Assurance Health needs (BOD) Required Health Interventions
- 36. Protocol Building for The Bahamas • World Health Organization • NICE National Health Institute for Health and Care Excellence • National Guidelines Clearinghouse • http://www.eguidelines.co.uk • http://www.ncbi.nlm.nih.gov • http://www.leitlinien.de • http://www.library.nhs.uk • http://www.guidelines.gov • http://www.nice.org.uk • http://medicine.ucsf.edu • http://www.cks.library.nhs.uk • http://www.guiasalud.es
- 37. Protocol Building for The Bahamas Hypertension Initial Encounter Primary Care Enrolment Clinical Management Age, comorbidity, medication Phatmaceuticals, Laboratories, Allied Primary Health Care Hospitals
- 39. TIMELINE February 28 March 1 to 13 group meetings March 14 to April 15 BP draft definition April 16 to 27 Presentation and incorporation of comments April 27 to 30 Final Draft Delivered
- 40. Vision of NHI • The Government of The Bahamas is committed to transforming the healthcare systems into the safest, most effective and most compassionate provider of healthcare in the region.
- 41. Next frontier -- Wicked Challenges • Access to all • Healing Environments • Work sharing and team work • Infection prevention • Culture of safety • Transitions of care
- 42. Conclusion • Barriers to change-culture eats strategy for breakfast (Peter Drucker) Slide: 42
- 43. References • More on topic and references for talk see https://www.linkedin.com/in/paulbarach • Key research papers are downloadable at Research Gate at https://www.researchgate.net/profile/Paul_Barach/ publications/?pubType=article&ev=prf_pubs_art • Email me at pbarach@gmail.com or contact me at Tel: 242 4289817