IHI



University of ChicagoGraduate Program in Health Administration and PolicyInstructorLaura K. BotwinickOffice Phone: 773-702-1324lbotwinick@uchicago.eduOffice hours by appointment (please email)T.A. – Rebecca Winitzerrwinitzer@uchicago.eduCourse InformationSpecial Issues in Healthcare Management SSA 46600, PPHA 46200/Spring 2010Location: SSA building, 969 E. 60th Street, Room WI Thursday: 5:30 – 8:20 p.m.March 30, 2010(revised May 13, 2010)Course Description - Special Issues in Healthcare Management This course addresses issues of quality, safety, effectiveness, equity, and efficiency in health care and provides students with knowledge to be agents of change and improvement. With the passage of major new health care reform legislation this month, the work to improve the health care delivery system continues. This course examines the health care organization and its interplay with patients, stakeholders within the organization, and the larger environment including policy, payment, accreditation and other factors. Students will review literature in health care quality, policy and administration and address local, state, national and international settings. This course is required of all students in the Graduate Program in Health Administration and Policy. This course may be used to fulfill management distributional requirement in the Harris School. Prerequisite: GSBC 85600 or PPHA 46100 or SSAD 47500.Course ObjectivesStudents will gain knowledge of the existence and magnitude of the variation in quality, safety and cost of health care in the U.S and the world.Students will develop an understanding of the resources that are expended on health care in the U.S. and factors that drive higher cost.Students will understand the factors impacting the delivery of safe and high quality care in health care organizations.Students will understand “Systems Thinking” and key concepts in patient safety such as Human Factors and Reliability.Students will gain familiarity with the concepts described in Institute of Medicine (IOM)’s Crossing the Quality Chasm. Students will learn about strategies and tools for improving health care at the level of the individual health care organizations and at local, state, national and international levels.Student RequirementsStudents are expected to attend all classes and to actively participate in class discussions.Students will be asked to read the assigned articles and chapters, submit two papers, and conduct two on-line modules on Quality and Safety. In addition, students will write a brief synopsis of one of the required readings and be prepared to present it in class. Online Modules: Students will complete two modules on Quality and Safety from the Institute of Healthcare Improvement (IHI) Open School. One is “QI 103: Measuring for Improvement”. The other is of the student’s choosing. The link to the Open School is: IHI Open School is free.? Each course takes?60 to 90 minutes?to complete and consists of several lessons taking 15-20 minutes each.? Students will take a short quiz at the end of each lesson. Print out or create a PDF of the page that says you successfully completed the course and submit it to Laura Botwinick. There are 11 courses in total. At your option, you may choose to complete all 11 courses to achieve IHI Open School Certification. Mid-Term Assignment: The mid-term paper will address concepts relating to Governing the Commons for a specific community of choice. Write a 5-page paper (1.5 line spaced, 12-point font, one-inch margins) describing a particular health care “commons”. Identify what organizations make up the commons, what population draws on the commons, and what resources are available. Apply Elinor Ostrom’s theory of “governing the commons” to this scenario.Final Exam: Write a 10-page paper (1.5 line spaced, 12-point font, one-inch margins) that applies the concepts discussed in this course to a question that is of interest to you. This might be an issue that has arisen in your practicum/internship or something that has come up in class. Relate the issue or question to concepts discussed in the Institute of Medicine’s Crossing the Quality Chasm. Pose the question or issue in the first paragraph of your paper, explore the issue, and take a position. Include references from the literature. The references do not count toward the page count.Grading PolicyMid-term25%Brief summary of an article 5%Attendance and Class Participation20%Open School Modules (2) 5% each = 10%Final Paper 35%Group Discussions on June 15%Total100%Due DatesFirst Open School Module – Student choice:Thursday, April 22Mid-term:Thursday, April 29Second Module – QI 103:Thursday, May 13Final Paper Topics to InstructorFriday, May 14Final PaperFriday, May 28 by 12 pm CST (early due date is because grades are must be submitted for graduating students on June 4 by 9 am)Roundtable discussionTuesday, June 1**Because of the deadline for submitting grades, the last class will be held on Tuesday evening, June 1 instead of Thursday, June 3.Course WebsiteMost lecture materials and selected course materials will be available on Chalk in the Library Course Reserves Section. Other materials will be available on the Internet and in a course packet. Week 1: April 1 – Welcome and Course Overview/Quality and Cost Variations in Healthcare Money Driven Medicine Documentary; Presentation & Discussion - Elmer AbboThe purpose of this session is to illustrate the impact of the current health care system on quality, cost and the patient experience of care. Students will gain an understanding of the various incentives and levers that impact policies and practice.Guest Speaker: Elmer Abbo, M.D., J.D., Assistant Professor of Medicine in the Section of General Internal Medicine, University of Chicago Medical Center Required Readings: *Atul Gawande, The Cost Conundrum: What a Texas Town Can Teach Us About Health Care, The New Yorker, June 1, 2009Wennberg, JE, Fisher, ES, Skinner, JS. Geography and the debate of Medicare Reform. Health Affairs. February 13, 2002. 3. Fisher ES, Bynum JP, Skinner JS, “Slowing the Growth of Health Care Costs – Lessons from Regional Variation, New England Journal of Medicine, February 26, 2009 * Articles with asterisks throughout this syllabus will be assigned for student write-ups. For Reference Only:Mahar M., Money-Driven Medicine, HarperCollins Publishers, 2006. Maggie Mahar is a financial journalist and writes for Money magazine, Institutional Investor, the New York Times, Bloomberg, and Barron's.Disparities In Physician Care: Experiences And Perceptions Of A Multi-Ethnic America, R.J. Blendon et al., Health Affairs, March/April 2008; 27(2): 507-517. Atul Gawande, The Cost Conundrum Redux, The New Yorker, June 23, 2010. 2: April 8 Performance Measurement in Health Care - The Good, The Bad, and The Ugly – Jerod LoebThis session focuses on methods for measuring health care quality. In addition, students will deepen their understanding of the Institute of Medicine framework in Crossing the Quality Chasm, and will learn about new frameworks for health care delivery that are being discussed in the current health care reform environment.Guest Speaker: Jerod Loeb, Ph.D., Executive Vice President for Performance Measurement and Research, The Joint Commission BreakCrossing the Quality Chasm & New Frameworks – Laura BotwinickRequired Readings:*Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century, Washington, D.C., National Academy Press, 2001, Executive Summary, Chapters 1, 2 & 8. (Available in packet, on reserve, or on online – viewing only).*McGlynn EA et al., "The Quality of Health Care Delivered to Adults in the United States", New England Journal of Medicine, 348(26), 2003 Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM. Quality of Care in U.S. Hospitals as Reflected by Standardized Measures, 2002-2004. New England Journal of Medicine; 353:255-264, 2005. *Elliott Fisher, et al., Creating Accountable Care Organizations: The Extended Hospital Medical staff: A new approach to organizing care and ensuring accountability, Health Affairs, 5 December 2006.*Berwick, et all, Triple Aim, Health Affairs, 2008 May-Jun;27(3):759-69. The triple aim: care, health, and cost.Medicare’s Opportunity to Encourage Innovation in Health Care Delivery, Robert Mechanic and Stuart Altman, New England Journal of Medicine, March 3, 2010. For Reference Only:Berwick, DM, A user’s manual for the IOM’s Quality Chasm” report. Health Affairs. 21(3):80-90, 2002. The Case for Keeping Quality on the Health Reform Agenda, E.A. McGlynn, Testimony presented before the Senate Committee on Finance, June 2008. Did They Do That? Low Cost High Quality Health Care in America Not the Best? A health care quality improvement resource. The Commonwealth Fund Accountable Health Care: Moving Forward in Medicare, Fisher et al., Health Affairs, January 27, 2009 Williams SC, Koss RG, Morton DJ, Loeb JM. Performance of Top-Ranked Heart Care Hospitals on Evidence-Based Process Measures. Circulation; 114:558-564, 2006.Williams SC, Koss RG, Morton DJ, Schmaltz SP, Loeb JM. Case Volume and Hospital Compliance with Evidence-Based Processes of Care. International Journal for Quality in Health Care; 20(2):79-87, April, 2008.Week 3: April 15 Governing the Commons – Laura BotwinickThe work of the Nobel Prize winning researcher, Elinor Ostrom, PhD, will be applied to the health care setting. Dr. Ostrom extends Garrett Hardin’s classic treatise on the “Tragedy of the Commons” to provide alternatives for addressing the management of shared resources. This class will explore the various models from state control to privatization, and options in between.During Class, watch Don Berwick, IHI Plenary Speech - “Squirrel”Assignment for Mid-term (Due April 29): Identify the boundaries, stakeholders, and resources available to the commons for a health care community of choice. No more than 5 pages. Required Reading:*"Governing the Commons: The Evolution of Institutions for Collective Action" by Elinor Ostrom, Cambridge University Press, 1990. Preface, Chapters 1, 2 & 6. (Available in packet or on reserve.)*"Rules, Games, & Common-Pool Resources" by Elinor Ostrom, Roy Gardner, and James Walker, The University of Michigan Press, 1994. Chapters 1, 14 & Conclusion. (Available in packet or on reserve.)Cassel, Christine K., and Troyen E. Brennan. 2007. "Managing Medical Resources: Return to the Commons?." Journal of the American Medical Association. 297(22):2518-2521. *Michael Porter, et al. Redefining competition in health care. Harvard Business Review. 82(6): 65-76, 2004. For Reference OnlyGarrett Hardin, "The Tragedy of the Commons", Science, Vol. 162, No. 3859 (December 13, 1968), pp. 1243-1248.Ostrom, Elinor, Joanna Burger, Christopher B. Field, Richard B. Norgaard, and David Policansky (1999): Revisiting the Commons: Local Lessons, Global Challenges, in: Science, Vol. 284, 9 April, pp. 278-282.Uwe E. Reinhardt, A “Government Takeover” of Health Care? Blog Entry. Strategy for Health Care Reform – Toward a Value-Based System, ME Porter, New England Journal of Medicine, July 9, 2009.Schlesinger M., Gray B., How Nonprofits Matter In American Medicine, and What To Do About It, Health Affairs - Web Exclusive, June 20, 2006, including Comments in response to the article.Arnold, RJ, Rich, RF, White WD, Editors. Competitive Approaches to Health Care Reform. The Urban Institute Press, Washington, D.C., 1993.Week 4: April 22 – Health Care Operations Management – Thomas J. BestFirst Open School Module Due – Student choice of moduleGuest Speakers: Thomas J. Best and Rachna “Priya” Khatri. Mr. Best is a Ph.D. candidate in Operations Management at the Booth School of Business. Ms. Khatri is an MBA candidate at Booth and a GPHAP participant. She worked for several years as Senior Operations Improvement Analyst at Methodist Hospital in Texas.Healthcare organizations of today are utilizing methods from other industries to address quality and patient safety, and to enhance hospital revenue and staff and patient satisfaction. This class will address ways to address the issue of efficiency and operations improvement in health care. Required Reading:James P. Womack and Daniel T. Jones, Beyond Toyota: How to Root Out Waste and Pursue Perfection, Harvard Business Review, September-October 1996.*System changes to improve patient safety, Thomas Nolan, British Medical Journal, 18 March 2000.McCarthy D., Blumenthal D, Stories from the Sharp End: Case Studies in Safety Improvement, The Milbank Quarterly, Vol. 84, No. 1 2006, pp. 165-200.4. *Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings. Institute for Healthcare Improvement. 2003 *In addition, a case study will be provided for discussion during class.For Reference Only:Breen AM, Burton-Houle TB, Aron DC. Applying the Theory of Constraints in Health Care: Part 1 - The Philosophy. Quality Management in Health Care. 2002, 10(3) 40-46.")Five System Barriers to Achieving Ultrasafe Health Care, Rene Amalberti, MD, PhD, et. al, Annals of Internal Medicine, 3 May 2005, Volume 142, Number 9.Industrial Engineering Glossary Primary Source: LEAN Glossary Week 5: April 29 - Patient Safety, Reliability, and Human Factors – Laura BotwinickThis class will address key concepts relating to delivering care safely in complex health care systems. The importance of understanding health care as a complex system will be address. Principles relating to human factors and reliability will be explored. The importance of teamwork, good communication, leadership and culture and will be understood and critical aspects of a well performing health care organization.During Class, watch Chasing Zero film.Mid-Term on Governing the Commons Due – Hard copy to be delivered to instructor in class on Thursday night.Required Reading:*To Err is Human: Building a Safer Health System. Washington, DC, National Academy Press, 2000, Executive Summary and Chapter 3. (Available in packet, on reserve, or on online – viewing only).Leadership Guide to Patient Safety, Laura Botwinick et al, Institute for Healthcare Improvement White Paper, 2006; Algorithm: James Reason, Responses to Errors James, Quality Improvement Opportunities in Health Care – Making it Easy to Do it Right, Journal of Managed Care Pharmacy. 2002 Sept/Oct; 8(5):394-399.*James Reason, Human Error: Models and Management, British Medical Journal, March 18, 2000; 320: 768-770*Leape LL., Error in Medicine, Journal of the American Medical Association. 272(23):1851-1857, 1994.*Bates DW. Gawande AA. Improving Safety with Information Technology, New England Journal of Medicine, 348 (25):2526-34, 2003.For Reference only:James Reason, Managing the Risks of Organizational Accidents, Ashgate Brookgate: 1997.G. Slavendy, Handbook of Human Factors and Ergonomics, John Wiley and Sons; New York: 1997.K. Weick and K. Sutcliffe, Managing the Unexpected: Assuring High Performance in an Age of Complexity. Jossy Bass; San Francisco, 2001.Gawande A. “When Doctors Make Mistakes.” Complications: A Surgeon’s Notes on an Imperfect Science. New York: Henry Hold and Company, 2002.Patient Safety and the “Just Culture”: A Primer for Health Care Executives, David Marx, April 2001. of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans, Rosemary Gibson and Janardan Prasad Singh, Lifeline Press, 2003.Health Care at the Crossroads: Strategies for Improving the Medical LiabilitySystem and Preventing Patient Injury, Joint Commission white paper. and Complex Systems: What Would Successful Reform of [Canadian] Medicare Look Like, Glouberman and Zimmerman, Discussion Paper No. 8, Commission on the Future of Health Care in Canada, July 2002.National Patient Safety Goals (NPSGs) 6: May 6 – Crises Happen. Plan Ahead - James B. ConwayMost organizations are tempted to react defensively and protectively when errors happen. It is understandable but the evidence is mounting that this approach is not optimal for patients, staff, or for the future health and vitality of the organization.Guest Speaker: James B. Conway, MS, Formerly, Senior Vice President, Institute for Healthcare Improvement (IHI) and Executive Vice President and COO of Dana-Farber Cancer Institute (DFCI). His areas of expertise include governance and executive leadership, patient safety, change management, and patient- and family-centered care. Required Reading:Massachusetts Coalition for the Prevention of Medical Errors. When Things Go Wrong: Responding to Adverse Events, A Consensus Statement of the Harvard Hospitals. March 2006. *James Conway, Patients and Families: Powerful new Partners for healthcare and for caregivers. Healthcare Executives. Jan/Feb 2008; 60-62.Bergeson SC, Dean JD. System Approach to Patient-Centered Care, Journal of the American Medical Association, December 20, 2006; 296(23): 2848-2851.Waterman, AD, Garbutt JG, Hazel E, et al. The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada. The Joint Commission Journal on Quality and Patient Safety, Aug 2007; 33(8): 467-476.Berwick, D., What 'patient-centered' should mean: confessions of an extremist.Health Affairs, 2009 Jul-Aug;28(4):w555-65. Epub 2009 May 19. Week 7: May 13 – International Perspectives & State Solutions– Laura BotwinickThe experience of other countries provides an important perspective as the U.S. continues to grapple with health care reform. This class will explore how other countries have addressed issues of access, quality and cost. In addition, states in the U.S. provide examples of alternatives to addressing health care challenges. The examples of states that perform well will be explored and lessons learned identified for application across the nation.During Class, Watch Frontline Program: Sick Around the World – DiscussRequired Reading:*Hussey PS, Anderson GF, Osborn R, Feek C. McLaughlin V, Millar J, Epstein A. How does the quality of care compare in five countries? Health Affairs. 23(3): 89-99, 2004.Murry C, Frenk J. Ranking 37th – Measuring the Performance of the U.S. Health Care System, New England Journal of Medicine, Jan 14, 2010,*The Commonwealth Fund, Aiming Higher for Health System Performance: A Profile of Seven States That Perform Well on The Commonwealth Fund's 2009 State Scorecard. Can States Pick Up the Health Reform Torch? New England Journal of Medicine, February 24, 2010, Rosenbaum S. For Reference Only:How Does the Quality of U.S. Health Care Compare Internationally?, Elizabeth Docteur and Robert A. Berenson, Urban Institute, August 2009.Testimony--U.S. Health Reforms to Improve Access, Outcomes and Value: International Insights and Innovative Policies, The Commonwealth Fund, October 2009, Reinhardt, Lessons from the Health Care Summit, Health Affairs Blog Entry Reinhardt BlogIs “Community Rating” in Health Insurance Fair Reinhardt BlogHow the World Balances Health Care Risk Patient Safety through State Reporting Systems, Jill Rosenthal, AHRQ Web M&M. Beyond Access: Achieving Equity in State Health Care Reform, Health Affairs, March/April 2008. 8: May 20 – Reducing Waste and Improving Patient Safety & Contributions of Accreditation – Dennis S. O’LearyThis session will address the impact of waste and inefficiency in the health care delivery system. In addition, the history and contributions of the Joint Commission, a leading standards setting and accreditation organization will be discussed. Guest Speaker: Dennis S. O’Leary, MD, President Emeritus, The Joint Commission, Oakbrook Terrace, Illinois. Dr. O’Leary will discuss:“Evolution of The Joint Commission in?Meeting Patient Safety and Quality Improvement Challenges” and “Reducing Waste and Improving Patient Safety”Required Reading:*Wachter RM. Patient Safety At Ten: Unmistakable Progress, Troubling Gaps. Health Affairs. Jan 2010;29:1-9. Shortell SM, Singer, SJ. Improving Patient Safety By Taking Systems Seriously. Journal of the American Medical Association. Jan 30,2008;299(4):445-44.Reinhardt?UE, Hussey, PS, Anderson, GF. U.S. Health Care Spending In An International Context. Health Affairs. May/Jun 2004;23(3):10-25.Anderson GF, Frogner BK. Health Spending?In OECD Countries: Obtaining Value Per Dollar. Health Affairs. Nov/Dec 2008;27(5):1718-1727. Aaron HJ. Waste, We Know You Are Out There. New England Journal of Medicine. Oct 30, 2008;359(18):1865-1867. *Bush RW. Reducing Waste in US Health Care Systems. Journal of the American Medical Association. Feb 28, 2007;297(8):871-874. *Emanuel, EJ, Fuchs VR. The Perfect Storm of Overutilization. Journal of the American Medical Association. Jun 18, 2008;299(23):2789-2791. Week 9: May 27 - Science of Improvement – Robert LloydSecond Open School Module Due – QI 103: Measuring for ImprovementThis session will provide an overview of the key milestones along the quality improvement journey. This session is built around the IHI Model for Improvement (MFI) and will demonstrate how to link the three questions related to aim, measurement and change concepts to the sequence for success (testing, implementing and spreading).Guest Speaker: Robert Lloyd, PhD, Executive Director of Performance Improvement, Institute for Healthcare Improvement, Cambridge, Massachusetts Required Reading:1. IHI Open School, Complete module QI 103: Measuring for Improvement2. Statistical Process Control as a Tool for Research and Healthcare Improvement, Benneyan JC, Lloyd, RC Plsek, PE, Quality and Safety in Health Care, 20033. Measuring for Improvement: Why, What, When, How, For Whom? Nelson, EC, Quality Connection, Spring, 1995. For Reference Only:"The Improvement Guide" by G. Langley, R. Moen, K Nolan, T Nolan, C Norman, L Provost, 2nd Edition, Jossey-Bass, 2009. Part One (Chapters 1, 2 & 3). Observational Studies, Randomised Trials, and Two Views of Medical Science, Vandenbroucke JP, PLoS Medical, March 2008.A Matter of Time, Lloyd, RC, Goldmann, DA, Journal of the American Medical Association, Aug 26, 2009.Why are so few Randomized Trials Useful, and what can we do about it?, Journal of Clinical Epidemiology, 2006.Monday, May 31 is Memorial Day HolidayFinal Paper due by noon on Friday, May 28. Send and electronic copy to lbotwinick@uchicago.eduSTUDENTS UNABLE TO ATTEND THIS CLASS MUST COMPLETE AN ADDITIONAL OPEN SCHOOL MODULE. Week 10: Tuesday, June 1/ (not June 3) – Student Roundtable Discussions Final presentation & comments from instructor.Student roundtable discussions. Affinity groups will be formed based on final exam paper topics. Students will share their paper with students in the group and discuss each other’s papers on June 1.Course evaluations.Tuesday, June 1 – Note: The last class has been changed from Thursday, June 3 to Tuesday, June 1 to accommodate the deadline for submitting grades. ................
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