Building Systems and Leadership for Transformation

Building Systems and Leadership for Transformation April 7, 2016 Dr. Uma Kotagal Senior Fellow Executive Leader, Population and Community Health Efforts Cincinnati Children s Hospital Medical Center

"It must be remembered that there is nothing more difficult to plan, more doubtful of success nor more dangerous to manage than the creation of a new system. For the initiator has the enmity of all who profit by the preservation of the old institution, the suspicion of those who don't understand, and merely lukewarm defenders in those who would gain by the new one. Niccolò Machiavelli

Our Beliefs We believe that we are all caregivers making children well is everyone s business. We believe that science and compassion are equally important. We believe that small acts have tremendous impact. We believe in each other colleagues, patients and families. We have the power to save lives through collaboration. Every person at Cincinnati Children s is here to nurture patients & families to better health and to help eradicate childhood disease through research, innovation, application, and a passion for the human spirit. We believe in sharing our ideas, our discoveries and our advancements so that children in Cincinnati and around the world can thrive. SP20: Changing the Outcome Together 3

E D E D Hospital Flow - Challenge of Team Families Nursing O R Patients Medical Staff Housestaff OutPatients I C U InPatients Multiple Sites All Interactive / Interdependent 4

What will it take Will Ideas Execution

Learning to See What will it also take Understanding the challenge Acting with intent Resilience and Persistence

Learning from Variation

FEV 1 % Predicted Variation in CF Outcomes - 1999 110 29.8% 100 90 80 70 Median values 34.8% 60 10 20 30 40 50 60 70 BMI Percentile Source: GT O Connor/Cystic Fibrosis Foundation

Design for Transformation

Organizational Transformation Pursuing Perfection Initiative challenged organizations to transform based on the IOM s New Rules for Health Care Defining transformation: Radical changes in how members of the organization perceive, think & behave at work. Fundamentally altering assumptions about how an organization functions. Significant shifts in corporate philosophy & values & structures that shape behaviors

Design Characteristics 1. Strategic improvement goals are part of our strategic plan and address the needs of our mission - patient care, research, education 2. Accountability for achievement of improvement goals is shared by all levels of the organization 3. Leadership for the improvement system is multidisciplinary and cross functional 4. Capability for improvement is built at the point of care and horizontally across CCHMC 5. Performance improvement is integral to the leadership system and integrated with daily work 6. Performance improvement is measurementbased/responsive/efficient/proactive/aligned 7. Consistent use of the science of improvement 8. Transparency of results and process 9. Constancy of purpose for improvement

SYTEM LEVEL MEASURES

System Level Measures ACCESS, FLOW, PRODUCTIVITY PATIENT AND EMPLOYEE SAFETY CLINICAL EXCELLENCE, OUTCOMES TEAM WELLBEING PATIENT AND FAMILY EXPERIENCE 3 rd next available appointment % of patients delayed: ED, PICU, PACU Adverse drug events Bloodstream infection rate Surgical site infection rate Codes outside the ICU rate/1,000 days MRT preventable codes outside the ICU Staff Satisfaction Nursing turnover rate Overall Rating: Patient Satisfaction (best possible) Patient Satisfaction (0-6 ) Touch Time for care givers Infection rates: VAP Serious Safety Events OSHA recordable injury rate Standardized PICU Mortality Ratio Expected/ Actual % use of Evidence-Based Care for eligible patients Clinical and Functional Outcome Improvement Risk Adjusted Cost per Discharge

Alignment

Alignment: Align measurement Alignment Align strategy and accountability Build improvement capability Integrate into daily work All strategic goals are part of each component of the organization with specific assignments

Organizing For Transformation Board Oversight Senior Leadership Focus System-Wide Goals CSI Goals Division/Microystem-Based Goals Individual Performance

Clinical Systems Improvement PATIENT/FAMILY Microsystems: Monitor & act on a dashboard of measures Inpatient Team Outpatient Team ED Team Peri-Op Team Home Care Team Mental Health Team Clinical & Non-Clinical Support Processes Develop, monitor & act on a dashboard of measures Comprised of Patient Services, Faculty, Administrative and Community Physician Leadership Develops, reviews & acts on System Level Measures Clinical System Improvement Integrating Team Board/ Leadership Team Provides strategic priority setting, resource allocation, organizational alignment Serves as champions/coaches to the Clinical Systems Improvement Teams and Sub-teams The Clinical System Improvement reports to the Patient Care Committee of the Board 18

Delivering on Operations PeriOp Virtual Site Visit Reliably in a Mesosystem B\\Barbara Tofani, RN Frederick C. Ryckman, MD.

Patient Experience Operational Excellence Optimizing Outcomes, Experience & Value Partner with Patients & Families Reliably Implement Situation Awareness Empowered & Accountable Leadership Maintain Resilient Staffing Build Engaged & Committed Teams Reliably Execute Key Processes Employee Experience Every Patient Integrated Care Delivery Every Time 20

Building a Team Having a Method Trusting the Science

Steve Muething, MD Fred Ryckman, MD Maria Britto, MD MPH Susan Miller, NP John Bucuvalas, MD Mike Farrell, MD

Operating Assumptions Building improvement capability at CCHMC goes beyond acquisition of knowledge and skills to action-oriented improvement that achieves critical results and accelerates transformation. As an Academic Medical Center, CCHMC s strategy for building improvement capability focuses on engaging and developing faculty as improvement leaders, educating trainees and advancing the scholarship of health care improvement through rigorous methods and quality improvement research. Different groups of people will have different levels of need for improvement knowledge and skill to achieve results, and each group should receive the training they need when they need it and in the appropriate amount. All members of the organization should incorporate improvement into their daily work and have the ability to advance their improvement knowledge and skills to achieve critical results, and function at any level of the CCHMC improvement ladder.

LEARNING NETWORKS Improvement Science Education: Current Portfolio CARE DELIVERY LEADERSHIP TEAMS ADVANCES IMPROVEMENT LEADERSHIP SYSTEMS (AILS) ADVANCED IMPROVEMENT METHODS (AIM) FACULTY DEVELOPMENT QUALITY SCHOLARS PROGRAM; RESEARCH MENTORING AIM EXTERNAL Intermediate Improvement Science Series (I 2 S 2 ) SYSTEM-WIDE, MICRO AND MESO SYSTEM LEADERS Intermediate Improvement Science Series (I 2 S 2 ) COMMUNITY Intermediate Improvement Science Series (I 2 S 2 ) TEAM PROJECT LEADERS Rapid Cycle Improvement Collaborative (RCIC) FRONT LINE IMPROVERS (ON-LINE MODULES) 25

Situational Awareness Looking at the system differently

Situation Awareness?

Prediction Flow as a Safety Initiative Framework for Safety Getting the Rights Right Right Diagnosis and Treatment Right Patient in Right Bed Location Right Nursing Staff and Staffing Expertise Disease Specific Expertise Equipment Expertise Best Care Model Requires ability to Predict future needs, and manage present capacity - control variability Operations Management techniques to understand and manage variability are the key to success

Critical Flow Failures 38 Months 39 Months 1 in 38 Months 39 Months

3 Level High Reliability Huddle for System Health Systems Excellence MICRO LEVEL (Unit Huddle) Look back: individual providers report on unexpected events, medical response team calls Look forward: individual providers report on individual patients at risk for safety events Integration: charge nurse considers overall unit status, planned discharges, staffing needs MESO LEVEL (Inpatient Huddle) Look back: charge nurses from each microsystem report on unexpected events, transfers to higher levels of care Look forward: individual microsystems report on higher risk patients in mesosystem, overall unit status Integration Manager of Patient Services (MPS) works with charge nurses to develop plans and predictions for highest risk patients, develop capacity plan through system, predict and mitigate experience failures MACRO LEVEL (Daily Operations Brief) Look back: mesosystem leaders report on unexpected outcomes over last 24 hours, resolution of concerns raised at previous brief Look forward: mesosystem leaders predict and plan for big issues of day with focus on problems at intersections of mesosystems Integration: administrator of the day identifies responsible party(ies) for each concerns and sets clear follow-up

Hospital Wide System 3 Times - Every Day Individual Room / Floor / System Predictions Capacity and Safety Floor Huddles PeriOp Huddle ED Huddle ICU Huddles Institutional Wide Bed Huddle Capacity Management Pharmacy Pt. Transport Facilities Institutional Wide Safety Call System Prediction Mitigation Strategy Security Housekeeping Pt Experience Leadership Outcomes and Prediction Meeting CEO, CFO, CMO, CNO, SIC, Sr VP s, Safety Director

Transforming Systems System Level Measures Leadership Alignment Engagement Improvement Capability/Capacity Science Moving from reactive to proactive

Being The Best At Getting Better

Improvement Open House June 8, 2016 September 8, 2016 October/November Dates TBD $500 per person For more information or to register: Jess Siebert 513-803-7173 Jessica.schraer@cchmc.org