Framework for Leading Improvement and Reducing Harm Indiana Hospital Association September 30, 2013 Michael D. Pugh michael@mdpassociates.com
The Critical Question How good is your hospital? 2
When YOU are the patient What is the right number of medication errors, infections or falls? Is it acceptable to spend 12 hours in the ED? What % of the time do you want to get the right care? Is it OK to transition home from the hospital without a real plan to keep you from coming back? 3
Patient Harm occurs because Every system is perfectly designed to produce the results it gets. Dr. Paul Batalden 4
What Patients Really Want Don t hurt me Help me Be Nice to Me Don Berwick, MD 5
So what s it going to take? 1. Leadership Engaged Boards and Executive Teams Clear Strategies and Focus Better Execution 2. New Mental Models and Strategies We have to think differently about both the challenges and the solutions 6
Mental Models & Theories Drive Leadership Actions and Behaviors Leadership Issue Commonly held Mental Models and Theories New Mental Models Patient Satisfaction Improve Facilities and & technology Improve Customer Service Improve the Patient Experience Patients as Partners in their care Role of Physicians Physicians as Customers Physician Cooperation Physician Engagement Physicians as Partners & Leaders Reduce Cost Manage resources & inputs Manage length of stay and access Remove waste from processes Redesign clinical care processes Performance Measurement Meet accreditation requirements Meet public reporting & compliance requirements Better Results for Patients Use Quality data for improvement Use Quality data to manage Perfect Care 7
Success in the Value World Requires Different Thinking Volume Value Patient Satisfaction Increase Top Line Revenue Complex All-Purpose Hospitals and Facilities Quality Departments and Experts Persons as Partners in their Care Continuously Decrease Per Unit Cost Care Organized by Business Model Quality in Daily Work- Everyone 8
New Mental Models for Health Care Delivery Persons as Partners in their Care Compete on value with continuous reduction in per unit cost Services reorganized to align with new business models Everyone is an improver 8
IHI Triple AIM Population Health Define Quality from the perspective of an individual member of a defined population Experience of Care Per Capita Cost Health Care Public Health Social Services Core organizational strategy Success is Leadership Dependent 10
Strategic Dilemma: In the new ACA world, which door will your hospital choose? Integrator Coordinator Partner 1 2 3 11
The Choices for Hospitals and Health Care Systems Integrator Economic Risk for Care Partner Coordinator Economic Risk for Volume 12
Which Door? Regardless of which Door is chosen, hospitals and health care systems must innovate in order to: 1. Redesign care to reduce gaps in the care process 2. Redesign care to be more effective 3. Redesign care to be safer 4. Redesign care to cost less 5. Redesign care to meet individual patient needs and preferences What matters to me 13
Strategies for Reducing Per Unit Cost (Examples: Cost/DRG, Cost/Admission, Cost/Procedure, Cost/Treatment, Cost/encounter) Traditional Strategy: Control Inputs Direct Inputs Supplies Labor Quality Strategy: Redesign and Remove Waste* Clinical Processes *waste = unintended variation, rework, error, valueless care, needless complexity, etc. Measures Financial Clinical Patient Experience Indirect Inputs Structure Technology Support Processes 14
The Innovator s Prescription A Disruptive Solution for Health Care Clayton M. Christensen 1. Disruptive Technological Enablers in Health Care The shift from intuitive medicine to empirical medicine to precision medicine and the ability to diagnose by cause rather than symptom 2. Disruptive Business Model Innovations Solution Shops (ED and diagnostic services) Value-adding process (Surgical procedures) Facilitated Networks (Chronic disease management) 3. Disruptive Value Network: Systemic Reform vs. Piecemeal Insertion Disruptions are rarely plug-compatible with the prior value network or commercial ecosystem 15
The Innovator s Prescription A Disruptive Solution for Health Care Clayton M. Christensen 1. Almost all innovations come from the outside at the expense of the incumbents (read: hospitals) 2. Acute Care cost is driven by the inherent complexity of hospitals with their multiple service lines and business models You cannot house multiple business models under one roof and be efficient--must separate the Solution Shop (diagnostic services) from the Value Added Processing (treatment/surgery). 16
Five New Financial Management Questions Leaders Need to Ask 1. How much does a routine hip replacement cost now (from diagnosis to discharge home)? 2. If perfect care is provided, how much should a total hip cost? 3. How can we redesign the hip replacement care process to reliably deliver it at the target cost? 4. Once the new process is in place, how can we reduce and manage variation? 5. Once we achieve a stable and reliable approach, how can we reduce the cost by at least 5% every year going forward? 17
New IHI Leadership Framework for Achieving Triple Aim Results Create Vision & Build Will Develop Capability Driven by Patients & Community Deliver Results Shape Culture Engage Across Boundaries for Triple Aim Results Draft 9/30/2013
Driven by Patients and Community Critical more than a nice idea Focus on What matters to me rather than What is the matter Involve patients in the redesign of care processes Give the data a human face when presenting information Bring patients and families into all improvement meetings, with meticulous listening Role model patient and family engagement in rounding 19
Putting Patients and Community at the Center Designing healthcare infrastructure in partnership with patient and community Patient involvement in treatment decisions Patients and families presence on quality committees Patient and Community Patient and family advocacy Patient experience considered a priority Promote listening and feedback from patients Give the data a human face Reinforcing the human element Bring patients and families into all improvement meetings Role model patient and family engagement in rounds 20 Begin all meetings with a patient story
Leadership Behaviors Use Patient Stories in Communications Be an Authentic Presence at the Front Lines Frequently interact with Patients and Families Be transparent about patient experience aims and results Driven by Patients and Community Engage Across Boundaries 21
Sometimes we cannot see what is in front of us When we measure harm, eliminate the denominator You don t need denominators to compare yourself to yourself, over time Denominators are often part of the problem (ADEs per 1000 doses, SSEs per 1000 patient days) Denominators make the problem abstract, rather than personal Jim Reinertsen, MD 22
What makes more sense if the right answer is 0? Traditional Display (Rates).005 ADEs /1000 doses 2.67 infections/1000 patient days.003 Falls with harm per/1000 patient days Actual Count 35 ADEs last month 220 hospital acquired infections last quarter 65 Patient falls 16 with harm last month 23
and whenever possible Put a face on the data Jim Reinertsen, MD 24 Used with Permission IHI 2013
Nicole H. 8/12/2008 Post-proced Cx Eugene B. 10/27/2008, 10/28/2008 Med Error, Fall Virginia L. 8/12/2008 Delay in Tx Helene C. 9/5/2008 Fall Chantal E. 6/26/2008 Inapprop Touching Baseline Serious Safety Events Calendar Year 2008: 46 Events Robert S. 10/13/2008 Fall Lester J. 9/5/2008 Fall Mary D. 3/9/2008 Med Error Kathy W. 12/16/2008 Post Proced Loss of Function Karen G. 8/5/2008 Proced Cx/Delay in Tx Baby Boy G. 3/25/2008 Med Error Priscilla W. 8/30/2008 Delay in Tx Mary C. 12/19/200 8 Gary B. Fall 6/13/2008 Fall Used with Permission IHI 2012 Cynthia K. 11/10/2008 Delay in Tx Lorena W. 11/10/2008 Post Procedure Death Robert B. 12/2/2008 Post Procedure Death Dougla s T. 10/18/2 008 Med Error Calvin P. 4/4/200 8 Med Error Lance D. 10/30/20 08 Delay in Tx Dale W. 10/12/20 08 Med Error Gwendoly n P. 25 10/28/2008 Wrong Implant
Patients Harmed 2009: 24 vs. 2008: 46 Loueene D. 9/23/09 Fall Dorothy R. 1/28/09 Delay In Treatment Edward R. 4/23/09 Wrong Side Procedure Juanita A. 5/14/09 Delay In Treatment Beverly S. 2/4/09 Med Error Monroe K. 5/18/09 Post Procedure Death Michael F. 8/20/09 Retained foreign object Robert D. 5/12/09 Post Procedure Death Brenda R. 10/14/09 Delay In Treatment Karen C. 9/28/09 Delay In Treatment James H. 10/25/09 Post Procedure Death Peggy P. 7/1/09 Burn 47% Reduction SSER from Dec. 08 Baseline 48% Reduction in # of events year to year Jerry Y. 11/7/09 Fall Johnny B. 11/9/09 Fall Sharenda W. 2/15/09 Med Error Lilliam C. 4/3/09 Retained foreign object Yoland C. 7/7/09 Delay in Treatment Willie B. 11/5/09 Helen C. Med Error Pauline M. 11/4/09 Delay In Treatment Used with Permission IHI 2012 11/2/09 Fall Donna S. 6/4/09 Retained foreign object Scott G. 9/5/09 Delay in Treatment Alma M. 11/6/09 Fall 26 Ronnie D. 11/3/09 Delay in Treatment
A 78% reduction through Nov. 2010 Sylvia L. 3/31/10 Delay In Dx Mary B. 5/22/10 Post Procedure Cx Marilyn C. 1/21/10 Med Error Ruby B. 5/30/10 Fall Frank S. 2/22/10 Surgery Cx Lois R. 4/16/10 Surgical Fire Lamar A. 6/3/10 Med Error Bruce C. 5/25/10 Delay In Dx Doyle L. 7/22/10 Med Error 27 Used with Permission IHI 2012
Create Vision & Build Will Leaders and Board members--clear and consistent Vision that focuses on quality Adopt bold, specific, system-level Safety, Quality, and Experience strategic aims Oversee system-level measures of progress toward those aims, using a strategic dashboard Leadership ownership of safety and quality results Systematic leadership review of results and improvement processes Leadership visibility in improvement work Sense-making for the organization setting priorities 28
Leadership Behaviors Promote Transparency and Share Results Create Focus through Personal Time & Attention Ask Inquiry Questions Communicate the Vision Every Day Create Vision & Build Will Be an Authentic Presence at the Front Lines 29
Develop Capability Promote knowledge development, first with self and then with team Invest in improvement science and support structures Foster collaboration and teamwork Recognize and reward innovation and promote idea generation, especially at the front lines Put the right business and organizational structure in place Match talent with the challenges Adapt and learn from others don t recreate the wheel 30
25 th Annual IHI Forum Orlando, FL Dec 8-11 Leadership Required for the New Era Mini-Course Monday, December 9 8:30 AM - 4:00 PM Michael Pugh Andrea Kabcenell Barbara Balik CEO Summit Tuesday, December 10 8:00 AM 3:15 PM A high-level meeting for C-suite executives. At this meeting, we ll learn from: Toby Cosgrove, MD, President and CEO, Cleveland Clinic Jason Leitch, DDS, MPH, National Clinical Lead for Quality, Scotland Stephen Swensen, MD, MMM, FACR, Medical Director for Leadership and Organization Development, and Professor, Mayo Clinic College of Medicine Darden Restaurant Group Executive Leadership Corporate Site Visit Monday, December 9 8:30 AM - 5:00 PM www.ihi.org/forum
Leadership Behaviors Mentor and Coach Teams & Individuals Role Model Improvement Methods and Thinking Encourage System Thinking Promote Collaboration and Teamwork Develop Capability Engage Across Boundaries 32
Deliver Results 1. Establish a set of projects and activities that will assure reaching the organizational goals 2. Install leaders in key projects and hold them accountable Part of daily leadership work, not extra 3. Remain focused and transparent on desired results 4. Review progress frequently and systematically and provide in-person feedback to teams 5. Require the use of proven project and process improvement methods 33
Leadership Behaviors Promote Transparency and Share Results Manage the Pace of Change Be an Authentic Presence at the front lines Ask Critical Inquiry Questions about Results and Barriers Deliver Results Role Model Improvement Methods and Thinking 34
New IHI Leadership Framework for Achieving Triple Aim Results Create Vision & Build Will Develop Capability Driven by Patients & Community Deliver Results Shape Culture Engage Across Boundaries for Triple Aim Results Draft 9/30/2013
Shaping Culture Organizational Culture is shaped by the interdependent actions and behaviors of leaders and by the system of leadership deployed. Individual Leadership Behaviors Leadership System and Structure Leadership Actions 36
Shaping Culture Leadership Actions (Domains of the Leadership Framework) Leadership System (Talent, structure, policy, process) Create Vision & Build Will Deliver Results Develop Capability Seven Leadership Leverage Points Triple Aim Initiatives Patient Safety Culture Lean/TPS Care Redesign Patient and Family Centered Care Talent Management HR Policies Meetings and communications Decision authority and process Organizational structure Rules Compensation and incentives Budget Process Financial Reporting Process Individual Leadership Behaviors (Across all Boundaries) Be patient-centered in word and deed Be an authentic presence Role-model improvement Communicate the vision Promote transparency Remain focused Engage across boundaries Coach teams/mentor individuals 37
Leadership Actions Needed to Support Culture Change Develop and articulate a vision Recognize and reward Promote teams and teamwork Shaping Culture for Improvement and Innovation Identify the behaviors required Understand the linkage actions and culture 38
Engaging Across Boundaries to Achieve Triple Aim Results Point of Care Delivery Other services and/or care (Internal) Other Providers (external) Family, Employer, Social Services and Community services that patients might need and engage 39
Engaging Across Boundaries: Actions and Strategies EMR, IT, Health Information Exchanges ACO/Shared Risk contracting Case Management/Care Management Healthcare Guides & Navigators Handoff Management- Looking upstream and downstream Multi-provider/social services/family/person discharge and care planning Multi-disciplinary Rounding and Care Planning Conferences (Team Medicine) 40
Leading Across Boundaries Establish a shared purpose Communicate a shared vision Ask questions and listen to responses Build consensus Show respect for the partner s business models and constraints Adopt a collaborative approach and demonstrate patience Volunteer resources when needed Ensure that the right people are in the room 41
Five Force-Multiplying Leadership Behaviors 1. Patient-centeredness: Be consistently patient-centered in word and deed. 2. Frontline Engagement: Be a regular, authentic presence at the frontline and a visible champion of improvement 3. Relentless Focus: Remain focused and constant on delivering the vision and strategy. 4. Transparency: Be transparent and require transparency about results, progress, aims, and even defects. 5. Boundarylessness: Encourage and practice systemthinking and collaboration across boundaries.
Leading Improvement and Innovation 10 Questions for Senior Leadership and Boards 1. How much time are we (the senior leadership team) really spending on our quality and safety aims? 2. How might we more effectively engage the medical staff in our improvement and safety efforts? 3. What answers would we get if we were to randomly ask 100 employees: What should be our top 3 initiatives to make care safer for patients? 4. Are we taking full advantage of the power of the Board to leverage and accelerate our rate of improvement? 5. Are our leadership actions and behaviors aligned to drive our desired organizational culture? 6. Do we know what we need to know and what capability do we need to have to accelerate improvement? 7. How are we bringing patient experiences into the daily work to motivate and align our staff? 8. What barriers exist to adopting policies and procedures from elsewhere that are proven to decrease harm to patients? 9. What should cost and how fast can we redesign care to achieve that target? 10. Can everyone on the senior leadership team articulate our safety aims and cite our current results? 43
HURRY, HURRY, HURRY!
Contact Information Michael D. Pugh President MdP Associates, LLC 719-671-2668 michael@mdpassociates.com http://www.mdpassociates.com 45