2017 IHI National Forum on Quality Improvement in Health Care Orlando, FL All Together or Not at All: The Snuggle for Existence Donald M. Berwick, MD, MPP President Emeritus and Senior Fellow Institute for Healthcare Improvement December 13, 2017 1
Black Holes Colliding (computer simulation) 2
One Part in One Sextillion 1 in 1,000,000,000,000,000,000,000 In the 93 million miles that separate the earth and the sun, that is The width of one atom! LIGO Observatory: Livingston, LA 3
LIGO Scientific Collaboration (LSC) 1000+ members, 90+ institutions, 16 countries www.ligo.org The LSC is the organization that conducts the science of LIGO Source: Gabriela González 2017 Nobel Prize in Physics Rainer Weiss, MIT Barry Barish, Cal Tech Kip Thorne, Cal Tech 4
The advanced GW detector network Detecting Gravitational Waves All together, or not at all. 5
The ICU Team at Work The ICU Team at Work 6
Supercooperators Nowak and Highfield The Snuggle for Existence (I)f you are a cooperator, you will find yourself surrounded by other cooperators so that what you reap is what you sow to succeed in life, you need to work together pursuing the snuggle for existence, if you like just as much as you strive to win the struggle for existence. Cooperation - not competition - underpins innovation. 7
The Snuggle for Existence Drs. Ed and Justin Coffey 8
Suicide Rates Among Henry Ford Medical Group HMO Members C. Edward Coffey MD / Henry Ford Health System: National Vital Statistics Reports. NEJM Catalyst (catalyst.nejm.org) Massachusetts Medical Society Ohio Perinatal Quality Collaborative Dr. Jay Iams Dr. Mary Applegate Dr. Carole Lannon 9
OPQC = 108 maternity hospitals in Ohio 75% decrease in early elective deliveries since 2008, >67,000 births shifted to term Dr. Ty Reidhead 10
Incidence of diabetes-related end-stage renal disease among adults aged 18 years, by race and ethnicity United States, 1996 2013 AI/AN Black Hispanic Asian White Special Diabetes Program for Indians (SDPI) MMWR, January 13, 2017, Vol. 66(1) Dr. Jennifer Walthall 11
Indiana Persons Living with HIV Disease as of December 31, 2014 Top Number: New HIV/AIDS Reports January 1, 2014 December 31, 2014 Bottom Number: Total Persons Living with HIV/AIDS including cases diagnosed in other states and currently living in Indiana as of December 31, 2014 Posey 11 LaPorte St. Joseph Elkhart LaGrange Steuben 30 7 Lake Porter 599 176 15 19 65 5 185 Noble DeKalb Marshall 1,185 164 Starke Kosciusko 20 20 8 17 Jasper W hitley Allen 34 Pulaski Fulton Newton 19 12 5 13 583 9 18 Miami W abash Huntington White Cass W ells Adams 13 19 Benton 23 Carroll 30 38 10 8 Grant Tippecanoe 6 Howard Blackford Jay Warren 69 Clinton 106 /8 Tipton 167 Madison Delaware 11 / Randolph Fountain 16 Montgomery Hamilton 6 Boone 113 197 9 20 28 Henry 238 36 W ayne Parke Hendricks Marion Hancock 54 Putnam 7 235 89 21 Rush 7 151 4,791 51 Shelby Fayette Union 67 Johnson /8 Vigo Clay Morgan 8 5 11 Franklin Owen 53 137 28 Decatur 274 28 Monroe Brown Bartholomew 5 18 Dearborn Sullivan 9 17 Ripley Greene 215 23 59 /17 Jennings 17 12 Jackson 16 Lawrence Ohio Knox 12 Martin Jefferson Switzerland 40 Daviess 31 /10 /26 Scott Washington 27 22 7 Orange /21 Clark Pike 25 14 12 Gibson Dubois Crawford 292 Harrison Floyd 8 15 17 Perry / W arrick Vanderburgh Spencer 34 10 34 131 321 8 11 Vermillion * The subject heading HIV Disease found within this document refers to a combined total of persons with HIV or AIDS including those where progression to AIDS has occurred. Note: Data are suppressed when counts are or if determined identifiable. Spotlight on HIV/STD/Viral Hepatitis, 2014 Indiana Annual Report, January 1, 2015 Page 9 Why Austin? Expanding epidemic of injection drug use heralded by dramatic increase in acute HIV infections 2006 2012 Suryaprasad Clin Infect Dis; 2014, 59(10):1411-1419 12
Spectrum of services One- Stop Shop Addiction Treatment Medical Care Laboratory Testing Epidemiology (state and federal) DIS (six states) Executive Order Resources Syringe Exchange Faith Based community Media and Messaging Jail Services Community Capacity Building Outbreak Insurance coverage (HIP 2.0) Major Progress in Scott County Number 120 100 80 60 40 Total number of persons who have enrolled in addiction treatment at the SSP location Average number of syringes needed by clients each day Number of new HIV infections diagnosed Syringe needs are stable More persons getting addiction treatment New HIV infections remain low No evidence of increased drug use 20 0 Source: Indiana State Department of Health, Indiana Family and Social Services Administration, and IU Fairbanks School of Public Health 13
Prof. David Shoemaker - LIGO How does collaboration happen at large scale to solve problems that cannot be solved any other way? What is the secret of snuggling? 14
All Together, or Not At All Chronic Illness and Aging Systemic Patient Safety Prevention Social Determinants of Health Costs Modern Technology Prevailing Theories Will Not Work The workforce is not trying hard enough lean on them Incentives will fix it Rig payment to force changes Regulations will fix it Tighten controls - Enforce goals Measurement is a primary driver Measure and report Formal experiments will point the way Use RCT s More technologies will solve it Build stuff If only professionals could seize the controls Require spread 15
Helping My Brother Survive NOT.. Try Harder INSTEAD Helping My Brother Survive NOT.. Try Harder INSTEAD We Are in This Together 16
Helping My Brother Survive NOT.. Try Harder Pay for Performance INSTEAD We Are in This Together Helping My Brother Survive NOT.. Try Harder Pay for Performance INSTEAD We Are in This Together Pride and Joy in Work 17
Helping My Brother Survive NOT.. Try Harder Pay for Performance Follow the Rules INSTEAD We Are in This Together Pride and Joy in Work Helping My Brother Survive NOT.. Try Harder Pay for Performance Follow the Rules INSTEAD We Are in This Together Pride and Joy in Work Use Principles Modify as Needed 18
Helping My Brother Survive NOT.. Try Harder Pay for Performance Follow the Rules Measure and Report INSTEAD We Are in This Together Pride and Joy in Work Use Principles Modify as Needed Helping My Brother Survive NOT.. Try Harder Pay for Performance Follow the Rules Measure and Report INSTEAD We Are in This Together Pride and Joy in Work Use Principles Modify as Needed Measure to Learn 19
Helping My Brother Survive NOT.. Try Harder Pay for Performance Follow the Rules Measure and Report Randomized Trials INSTEAD We Are in This Together Pride and Joy in Work Use Principles Modify as Needed Measure to Learn Helping My Brother Survive NOT.. Try Harder Pay for Performance Follow the Rules Measure and Report Randomized Trials INSTEAD We Are in This Together Pride and Joy in Work Use Principles Modify as Needed Measure to Learn Focused Empiricism 20
Helping My Brother Survive NOT.. Try Harder Pay for Performance Follow the Rules Measure and Report Randomized Trials More INSTEAD We Are in This Together Pride and Joy in Work Use Principles Modify as Needed Measure to Learn Focused Empiricism Helping My Brother Survive NOT.. Try Harder Pay for Performance Follow the Rules Measure and Report Randomized Trials More INSTEAD We Are in This Together Pride and Joy in Work Use Principles Modify as Needed Measure to Learn Focused Empiricism Less 21
Helping My Brother Survive NOT.. Try Harder Pay for Performance Follow the Rules Measure and Report Randomized Trials More Doctors Rule INSTEAD We Are in This Together Pride and Joy in Work Use Principles Modify as Needed Measure to Learn Focused Empiricism Less Helping My Brother Survive NOT.. Try Harder Pay for Performance Follow the Rules Measure and Report Randomized Trials More Doctors Rule INSTEAD We Are in This Together Pride and Joy in Work Use Principles Modify as Needed Measure to Learn Focused Empiricism Less Only a Team Can Succeed 22
How to Snuggle Clear, Common Purpose (the glue is aim ) All Together, or Not at All A Safe Vessel Permission to Fail Shared Honor Affection Within, Not Accountability from Outside Only Leaders Can Set the Conditions 23
Common Threats and Challenges Chronic Illness 24
Causes of Mortality in Brazil (The Lancet 2011. 377:1877-1889) % of Population 65 Years Old: 2015 and 2050 25
Common Threats and Challenges Chronic Illness Social determinants of health Rising costs Not All Health Care Helps: Overuse 26
Common Threats and Challenges Chronic Illness Social determinants of health Rising costs New technologies Globalization of health threats Imbalance of acute care and prevention Workforce stresses Quality defects safety, etc. Spread of successes Current Designs Are Unfit for Purpose Hospital centric Fragmented health and social care Lagging technologies Guilds 20th century workforce for 21 st century needs 27
Three Panels on Global Care Quality Syringe-Sharing Network of Persons with Newly Diagnosed HIV Infection. 536 unique persons 1058 unique contacts Contact Type (1-56) Frequenc y Syringe-sharing 841 (79.5%) Sexual 81 (7.7%) Syringe/Sexual 136 (12.8%) Social Contact 83 (15.4)% Peters PJ et al. N Engl J Med 2016;375:229-239. 28
Continuum of HIV care in Austin, Indiana November 9, 2017 100 90 80 70 60 50 40 30 20 10 0 100% 100% 75% 55% Eligible* Engaged in Care** Care coordination Virally suppressed*** N=217 N=21 N=12 N=163 Total diagnosed=227 (226 confirmed). Persons were 7 ineligible if deceased 0 (n=7) or outside of the jurisdiction (n=3); estimates are based on the number of eligible persons (n=217);** Patients engaged in care if have at least one VL or CD4 *** Percent virally suppressed is stable at 75% when denominator changed to number engaged in care. Clinical services were initiated 3/31/15. 29