Dr Robert Petzel, Under Secretary for health, Veterans Health Administration talking at The King's Fund Annual Conference 2010 on transforming health services.

1. Health System Transformation Robert A. Petzel, M.D. | Under Secretary for Health

2. Veterans Health Administration Budget…………………........................................…..$50 Billion Medical centers………………………………………………..153 Outpatient clinics……………………………………..………850 Unique patients treated…………………………….…6 Million Outpatient visits……………................................….78 Million Employees………………………………………………...250,000 Physicians………………...................................….….....19,000 Nurses (RN)………………………………………….…..…45,000 Nurse Practitioners………………………………..….……3,500 2

3. What drove the change? A vision for change Structural re-organisation Decentralisation Evidence-based medicine Performance measures Performance management Electronic medical record Integration 1 2 2 3 4 5 6 7 8 3

4. The Transformation Vision1996 The Veterans Health Administration is a comprehensive, integrated health care system that provides excellence in health care value, defined by quality, cost, access and satisfaction. An organisation characterised by accountability and being an employee of choice. 4

5. 21 Veterans Integrated Service Networks in 1998 VISNs are the Funding & Accountability Unit in VA 1995: Creating VISNs Objective to transform from a ‘hospital system’ to a ‘health system’ From ‘safety net’ to ‘health promotion and disease prevention’ 5

6. Sample performance measures 1997 Decrease BDOC by 19% Increase ambulatory surgery by 20% Chronic disease index Prevention index Implement 12 new clinical practice guidelines ✓ ✓ ✓ ✓ ✓ 6

7. Outpatient visits vs BDOC 7

9. Patient satisfaction VHA has led private sector health care in patient satisfaction. NM = Not Measured Source: http://www.theacsi.org 9

10. Electronic Health Record 10

11. Why is IT a central strategy? Healthcare in the U.S., presents multiple challenges Information 1 in 7 hospital admissions occurs because care providers do not have access to previous medical records* 12% of physician orders are not executed as written* 20% of laboratory tests are requested because previous studies are not accessible* 1 in 6.5 hospitalisationsare complicated by drug error 1 in 20 outpatient prescriptions *PITAC (President’s Information Technology Advisory Committee, 2004) 11

12. Transformation 2010

13. Vision VHA will continue to be the benchmark of excellence and value in healthcare and benefits by providing exemplary services that are both patient-centered and evidence-based. This care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery and continuous improvement. It will emphasise prevention and population health and contribute to the nation’s well-being through education, research and service in national emergencies. 13

14. Transformational initiatives Patient-aligned care teams – PACT Telemedicine Transparency ✓ ✓ ✓ 14

15. PACT Patient Aligned Care Teams ✓ ✓ ✓ ✓ ‘Changing the paradigm from episodic care to longitudinal engagement’ -Robert Jesse, MD 15

16. PACT Patient-centered Team care Continuous improvement Evidence-based, data driven ✓ ✓ ✓ ✓ 16

17. 12 principles of patient-centered care Honor the veteran’s expectations of safe, high-quality, accessible care. Enhance the quality of human interactions and therapeutic alliances. Solicit and respect the veteran’s values, preferences and needs. Systemise the co-ordination, continuity and integration of care. Empower veterans through information and education. Incorporate nutritional, cultural and nurturing aspects of food. 1 2 3 4 5 6 17

18. 12 principles of patient-centered care continued Provide for physical comfort and pain management. Ensure emotional and spiritual support. Encourage involvement of family and friends. Ensure that architectural layout and design are conductive to health and healing. Introduce creative arts into the healing environment. Support and sustain an engaged workforce as key to providing patient-centered care. 7 8 9 10 11 12 18

19. Team care Everyone is on a team Team members are peers Collaboration Culture of respect ✓ ✓ ✓ ✓ 19

20. Continuous improvement Data Methodology Time Empowerment ✓ ✓ ✓ ✓ 20

21. Data-driven and evidence-based Data at point of care about cost, quality, access and satisfaction Practice to the evidence ✓ ✓ 21

23. personal visits

24. group clinics

25. telephone conversations

26. secure messaging through My HealtheVet

27. web access

28. telehealth22

30. personal relationships

31. patient preferences

32. open communication and sharing of information

33. team delivery of holistic care

34. co-ordination across specialties and settings of care

35. quality and safety improvements.23

36. PACT Compass Panel management Outcomes Access Continuity Satisfaction Co-ordination 24

37. PACT Compass 25

38. Transparency 26

40. Includes 50 metrics

41. Examples: MRSA, VAP, CLAB infection rates, hospital-acquired pressure ulcers, incorrect surgery, risk adjusted, standardised mortality rates for AMI, CHF, pneumonia and all cause re-admission rates27

43. Contains 45 process and outcomes metrics

44. Examples: Standardised mortality ratios for acute care (30 day) and ICU (in hospital & 30 day), and surgery (30 day), AMI, CHF, and pneumonia patients; risk adjusted re-admission rates (AMI, CHF and pneumonia); all cause re-admission rates, ambulatory care sensitive condition hospitalisations, hospital-acquired infections, etc28

45. Telemedicine 29

47. dermatology

48. ophthalmology

49. cardiology

50. pathology

51. mental health

52. Telehome Health

53. eICU30

55. 50,000 unique patients in FY 2010

56. Telemedicine

57. FY 2010

58. 73,000 unique patients

59. 165,000 encounters

60. Mental health

61. 100,500 unique patients over a four year period

62. Teleretinal imaging

63. 155,780 encounters in FY 201031

64. What drives the change? A vision for change Structural re-organisation Decentralisation Evidence-based medicine Performance measures Performance management Electronic medical record Integration Constancy of purpose 1 2 3 4 5 6 7 8 9 32