GETTING STARTED KIT. Conversation Ready Health Care Community

GETTING STARTED KIT Conversation Ready Health Care Community December 2013

Contents Welcome 3 Background 4 Overview of the Community Experience 7 Prework Components 9 Project Team Contact Information 9 Focus Population and Pilot Setting Worksheet 11 Project Aims Worksheet 12 Organizational Background Assessment and Chart Audit 13 Extranet Registration 13 Team Photo 14 Appendix A: Prework Packet 15 Appendix B: Attributes of Highly Effective Teams 22 Appendix C: IHI Project Team and Faculty 24 References 25 Institute for Healthcare Improvement ihi.org 2

Welcome On behalf of the entire Institute for Healthcare Improvement (IHI) team and faculty, we welcome you to the Conversation Ready Health Care Community. As a participating site, you join a cohort of energized and capable organizations dedicated to developing and piloting processes to create systems within health care to prompt discussions with patients and families about health care directives or end-of life wishes, and to record, access, and follow their instructions for care preferences at the end of life. As a community, we ll innovate together as we work toward a standard set of outcome measures that matter to patients and their families. This document provides background information and activities that will help you prepare for your participation in the Conversation Ready Health Care Community. We look forward to working with you. Best, The Conversation Ready Health Care Community Team and Faculty Institute for Healthcare Improvement ihi.org 3

Background The Challenge Imagine an 80-year-old woman who is admitted into your health care system with the medications allergy field in her electronic medical records left blank, or with a Y for yes with no further information. She moves in and out of your system, across care boundaries, without further clarification of this allergy field, until eventually the very medicine she is allergic to is administered to her. We would label this medication administration as a medical error that compromises patient safety and quality of care, and we would seek to change the system to prevent future recurrence of this error. Now imagine this same 80-year-old woman moves through your system with no documented information about her advance directive (beyond a possible Y for yes), her end-of-life wishes, or any documentation of what matters to her when it comes to care at the end of life. She has been rehospitalized four times in the past six months and eventually she dies in the intensive care unit, away from home, where she would have preferred to be. In most settings, this would not be considered an error and the system would be oblivious to the fact that sub-par care had been provided. Many institutions have not built systems that reliably engage with patients to understand what is most important to them with regard to their end-of-life care, to become stewards of this information, and to record, access, and respect these wishes in a timely way in an effort to provide more patient-centered care planning for all seriously ill patients, particularly those who are expected to die within the next five years. One 2013 study 1 identified how large the gaps are when it comes to patients and their families making sure that end-of-life care wishes are known and documented, and then having those wishes respected by health care providers: Before hospitalization, most patients (76.3%) had thought about end-of-life (EOL) care, and only 11.9% preferred life-prolonging care; 47.9% of patients had completed an advance care plan, and 73.3% had formally named a surrogate decision maker for health care. Of patients who had discussed their wishes, only 30.3% had done so with the family physician and 55.3% with any member of the health care team. Agreement between patients' expressed preferences for EOL care and documentation in the medical record was 30.2%. Family members' perspectives were similar to those of patients. Just over a year ago, The Conversation Project, in collaboration with IHI, launched a public campaign dedicated to encouraging people to talk about their wishes for end-of-life care with their loved ones, around the kitchen table rather than in the midst of a health care crisis. Too often, people die in ways they wouldn t choose. We know that, when surveyed, 70% of Americans indicate that they would prefer to die at home, and yet 70% die in the hospital. 2 Responses to The Conversation Project survey conducted in 2013 indicated that although more than nine in ten Americans think that it is important to talk about their and their loved ones end-of-life care wishes, fewer than three in ten have had that conversation. 3 In 2012, the Institute for Healthcare Improvement, a group of end-of-life care experts, and ten Pioneer Sponsors launched the Conversation Ready initiative for one year. Together, this group Institute for Healthcare Improvement ihi.org 4

committed to establishing what it means for a health care organization to be Conversation Ready that is, to be ready to receive an activated public and to record, and later respect, their wishes. Beth Israel Deaconess Medical Center (Massachusetts) Care New England Health System (Rhode Island) Contra Costa Regional Medical Center (California) Henry Ford Health System (Michigan) Mercy Health (Ohio) North Shore Long Island Jewish Health System (New York) St. Charles Health System (Oregon) UPMC (Pennsylvania) Virginia Mason Medical Center (Washington) Gundersen Health System (Wisconsin) leader in advanced care planning Focus for This Work After a year of rich and valuable learning with the Pioneer Sponsors, IHI is now launching the Conversation Ready Health Care Community, seeking broader participation by innovative organizations committed to working with us to continue developing reliable care processes that are informed by the following core principles (which we expect to further evolve in the year ahead): 1. Engage with all patients and families to understand what matters to them at the end of life; 2. Steward this information as reliably as we do allergy information; 3. Partner with patients and families to develop appropriate goals of care at the end of life; 4. Exemplify this work in our own lives, so that we understand the benefits and challenges; and 5. Connect in a manner that is culturally and individually respectful of each patient and their family. Engage Steward Partner Exemplify Connect Institute for Healthcare Improvement ihi.org 5

The Conversation Ready Health Care Community is a nine-month effort that focuses on the reliable delivery of care for patients before and at the end of their lives, and seeks to understand our patients and their lives beyond a problem list. The needed improvements are multi-factorial and involve many components, including communication; care planning; respectful, patientcentered care; cultural competence; staff engagement; and effective, patient-centered information systems. While the amount of time needed to transform the system will depend on the organization and scope of work, participating organizations can expect that true cultural transformation will likely take a few years. We encourage participating teams to start their work within the Community in an area where there is already will, strategic alignment, and focus within their organization. It is important to be realistic about what can be accomplished within this ninemonth period, while also planning additional work in the future. It takes time to successfully change the system and fully engage the team. Institute for Healthcare Improvement ihi.org 6

Overview of the Community Experience The collective knowledge of the Community participants, coupled with IHI s improvement expertise and guidance, give organizations a strong framework for taking action and achieving, sustaining, and spreading breakthrough improvements. Participating health care organizations, faculty, and staff will work together to improve care and systems. We will strive to have teams meet the goals within nine months by sharing ideas and knowledge, learning IHI s methodology for change, testing and implementing change concepts, and measuring progress. The objective of this results-oriented Community is action that leads to improvement. Methods The Community involves dedicated organizations working together intensely to achieve significant improvements. Over nine months, teams participate in two virtual Learning Sessions (at the beginning and end) and one in-person Learning Session, and maintain frequent contact with each other and faculty members through conference calls, listserv discussions, email, individual coaching calls, and monthly progress reports. Expectations of IHI and Participating Organizations The Institute for Healthcare Improvement and the Community faculty will: Provide a designated IHI Director and Project Manager, in addition to faculty who have expertise in the subject matter and improvement methods; Provide information on subject matter, application of that subject matter, and methods for process improvement, both during and between Learning Sessions; Offer guidance and feedback to teams; and Provide communication strategies to keep teams connected to the Community faculty and colleagues. Participating organizations are expected to: Connect the goals of the Community to a strategic initiative in their organization; Designate a senior leader to serve as sponsor for the team; Provide the resources to support their team, including time to devote to this effort (the equivalent of approximately one full-time equivalent [FTE] for project management for the duration of the Community for activities such as weekly team meetings, time for the team to conduct PDSA [Plan-Do-Study-Act] cycles to rapidly test changes, collect data, complete reports, etc.), and active senior leadership involvement in the work; Share information with the Community by creating and posting monthly reports that include a narrative description of changes tested and results, and creating run charts of data showing progress towards the aim using the IHI Extranet; Perform tests of change leading to process improvements in their organization; Participate in three Learning Sessions (two virtual and one in-person); Institute for Healthcare Improvement ihi.org 7

Participate in monthly calls; and Make regular, substantive contributions to discussion threads of the Community listserv. Overview of Activities All information about Learning Sessions, calls, and webinars will be posted to the IHI Extranet to ensure that the most up-to-date information is available. The calendar below outlines the activities and time frame for your organization s participation in the Community. (More specific dates will be provided as the work progresses.) Key Known Dates: Learning Session 1 (Virtual): February 13-14, 2014, 12-4pm ET Monthly Outcomes Data Submission: Due the 15 th of each month Identify and meet with your team prior to Learning Session 1 (virtual) Jan 2014 Feb 2014 Complete prework activities Participate in Learning Session 1 (virtual) Join launch webinar with your team Submit prework to IHI Participate in Learning Session 2 in Boston, MA (in-person meeting) Mar 2014 Apr 2014 May 2014 Join monthly webinars with IHI Participate in office hours coaching calls Monthly outcomes data submission Participate in Learning Session 3 (virtual) Jun 2014 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Institute for Healthcare Improvement ihi.org 8

Prework Components Below is a summary of the prework components. The complete prework packet can be found in Appendix A. 1. Project Team Contact Information 2. Focus Population and Pilot Setting Worksheet 3. Project Aims Worksheet 4. Organizational Background Assessment and Chart Audit 5. Extranet Registration (action item, no submission required) 6. Team Photo ACTION ITEM: Please submit your completed prework and your team photo to IHI Project Coordinator, Aka Kovacikova, at akovacikova@ihi.org by February 3, 2014. Project Team Contact Information You will be expected to designate a dedicated a Day-to-Day Leader for this work, as well as identify a core project team. Team roles for the core team are described below. Please see Appendix B for additional information on establishing highly effective teams. Key to the success of an improvement project is a small, committed improvement team. This is the team that will attend all Community activities, learn the content, and then, most importantly, learn how to make changes that matter in your organization. This team will learn what changes will lead to breakthrough improvements and what changes your organization will want to implement and then spread. Day-to-Day Leader (Key Contact): The Day-to-Day Leader is the critical driving component, ensuring that changes are tested and implemented and overseeing data collection and reporting. It is important that this person understands not only the details of the system being improved, but also the various effects of making changes in the system. This person needs to be able to work effectively with the clinical champion(s), other technical experts, and leaders within the organization. A Day-to-Day Leader should: Have a working knowledge of the area selected; Be able to organize and coordinate a functioning team that works at an accelerated pace; Have skill in project management and ensuring that the work of the improvement team gets done (experience with improvement projects is ideal); Have time allocated by senior leadership to work on this project; and Be motivated and excited about change and creating new designs. Sponsor/Senior Leader: The Sponsor is the person accountable to the organization for the performance and results of the improvement team. This person is generally not a member of the improvement team, but is a support for the team to accomplish their aim. The Sponsor/Senior Leader is responsible for: Encouraging the improvement team to set its goals at an appropriate level to meet organizational goals and agree on the team charter; Institute for Healthcare Improvement ihi.org 9

Providing the team with the resources needed, including staff time and operating funds, and also a financial team member to help document the business case and help the improvement team with other cost issues; Making it clear to the team that they have the time, resources, and authority needed to change organizational systems to accomplish their goal. Our experience is that the total resources required to do this work will be at least one full-time equivalent (FTE) for the Day-to-Day Leader, for activities that include management of the project, weekly meetings for the improvement team, time for the core team to attend all Learning Sessions and monthly calls; Ensuring that improvement capability and other technical resources are available to the team; Regularly reviewing the work of the team; and Developing a plan to spread the successful changes from the improvement team to the rest of the organization, including: Communicating what is learned from the improvement work in ways that motivate and mobilize the entire organization; and Designating someone who will be responsible for leading the activities needed to support spread. Technical Expert(s): A technical expert is someone who knows the subject matter intimately and who understands the affected processes of care. Additional technical support may be provided by an expert on improvement methods, who can help the team determine what to measure; assist in design of simple, effective measurement tools; and provide guidance on collection, interpretation, and display of data. Examples of technical expertise for this work are physicians, social workers, nurses, palliative care specialists, etc. We strongly encourage interprofessional representation on your team and to enlist clinical champions. These champions should have a good working relationship with colleagues and with the Day-to-Day Leader, and should be interested in driving change in the system. Look for professionals who are opinion leaders in the organization, to whom others go to seek advice, and who are not afraid to implement change. Patient(s) and Family Member(s): Patients and families bring critical technical expertise to the improvement team. Patients and families have a different experience with the system than providers and can identify key issues that need to be addressed. We recommend that each team has at least one patient or family member (ideally more than one), or a way to elicit feedback directly from patients at your site (e.g., through a Patient and Family Advisory Council). Additional information about appropriately engaging patients and families in improvement efforts can be found in the Free downloads section of the Tools for Change section of the Institute for Patient- and Family-Centered Care website at www.ipfcc.org. IS/IT Member(s): A key component of the work in the Conversation Ready Health Care Community is stewardship of patients end-of-life wishes through effective and reliable information systems. Regardless of your starting area of focus, we encourage you to have participation at the outset from someone on your IT/IS team so that effective technological solutions are approached proactively rather than as an afterthought. The experience of the Conversation Ready Pioneer Sponsors suggests that this is critical. Institute for Healthcare Improvement ihi.org 10

Other Team Member(s): Much of the innovation work in the Community will be focused on the design of new processes. Other persons who are integrally involved in the current processes within the organization should be considered for participation on the improvement team. Team members should also include those with direct care responsibilities. ACTION ITEM: Please complete the Project Team Contact Information in the prework packet (Appendix A). Focus Population and Pilot Setting Worksheet This prework should help organizations identify a pilot population and location for your work during the Community. Consider selecting a population (examples below) for whom there is strong agreement in the organization that care needs to be improved people for whom process improvement will quickly decrease suffering. By starting with this population, the organization can align improvement efforts with strategy and preexisting commitment. This is in contrast to starting your work with a population that is likely to create internal friction (e.g., patients a physician group would be unlikely to give up on), which could burn immediate energy and good will. For example, if your organization is already focused on preventing readmissions then you might align your work with those efforts. One Conversation Ready Pioneer Sponsor, North Shore-LIJ Health System, began their comprehensive Advanced Illness Care Planning efforts by focusing on patients who were age 85 or older (gerogeriatric) and had been admitted three or more times in the prior 90 days. Because the team agreed on the need, they were able to start testing more quickly and, in short order, begin to expand that segmented population to a younger age and longer span of readmissions. Other examples of segmenting include the following: Use the surprise question 4 during ICU rounds; those patients for whom the response is, No, it would not surprise me if this patient died within a year, are counted in the pilot population. Use the Norton triggers during rounding. 5 Engage with all patients over the age of 70 in a primary care setting who have a chronic disease. In residential settings, new interventions, such as discussing feeding tube placement with a surrogate for a resident with advanced dementia, can trigger the need for deeper work on these fronts. The IHI Project Team for the Conversation Ready Health Care Community is available to talk with you about determining your population segment and pilot location. ACTION ITEM: Please complete the Focus Population and Pilot Setting Worksheet in the prework packet (Appendix A). Institute for Healthcare Improvement ihi.org 11

Project Aims Worksheet At the start of any improvement effort, it is critical to ask the question, What are we trying to accomplish? Writing down an improvement aim sets direction, clarifies what is within the team s scope of work, builds consensus, and engages stakeholders. Sample aim statements are provided below. Although the Conversation Ready work currently delineates five core principles (Engage, Steward, Partner, Exemplify, Connect), we do not recommend that any organization tackle all five at once. Over the past year, the Pioneer Sponsors tested changes related to one to three of those core principles; examples follow. Beth Israel Deaconess Medical Center focused on changing their IT system to support reliable storage and retrieval of patient information about advance directives and end-of-life wishes. This work continues, along with the development of a story database to garner will among colleagues for their larger efforts. Care New England focused on piloting a novel staff position, a Conversation Nurse, who is seeing palliative care referrals for whom the primary need is to identify end-of-life wishes and then align care planning with these wishes. UPMC focused on staff engagement in having the end-of-life conversations with patients and families through an annual Day of Conversation and an innovative Partners program in ICUs to increase proactive and reliable communication with families of critically ill patients. Henry Ford Health System is engaging community faith leaders to promote mutual understanding of end-of-life care while also revising their standard advance directive forms and making their electronic medical record align more to the needs of documenting directives and care planning conversations. Focusing on a reasonable amount of work during the nine months of the Community, while also setting a vision for your organization s longer-term goals, are both critical for success. Early in your Community experience, you will be asked to set an aim that represents your goals for the nine months we will work together. The IHI Project Team is available to provide coaching as you develop your aim. The prework exercise will help identify your team s initial areas of focus and aim statement. Below are three sample aim statements, for your consideration as you develop your own. Marietta Valley Medical Center will focus initial Conversation Ready Health Care Community participation in the SICU and MICU with all patients who have had a prior admission in the last three months. Goals (by October 31, 2014): 1) Raise documentation of DPOA from 37% to 75%; 2) Random monthly chart audit review for patients who have died on these units will show that 75% have documentation of a goals of care discussion, and 50% have documentation of alignment of patient wishes with care received at time of death. We will conduct two qualitative interviews monthly with patients, as able (and families, as needed) in MICU and SICU patients who met readmission criteria to confirm/deny alignment of patient s wishes with plan of care and to discuss their experience while hospitalized. Stony Hill Nursing Care Center will conduct Conversation Groups with 75% of nursing staff by October 31, 2014, with particular attention to night and weekend shifts. Additionally, monthly chart audit will document that 80% of residents who have changed level of care within the Center have a documented note about end-of-life wishes and copies of any advance Institute for Healthcare Improvement ihi.org 12

directives will be present in the chart. Each month, we will meet with two families of residents who have died to discuss alignment of end-of-life care with residents wishes and their own experience of care as loved ones. By October 31, 2014, Loma Alta Hospital will have a field in the EMR that receives scans of advance directives along with flagged clinician notes about pertinent goals of care conversations. We will test scanning and flagging processes on unit 5W before broader testing of the new EMR field on other units. Additionally, we will convene a meeting with local faith leaders by July 2014 to increase mutual understanding of end-of-life care issues and increase collegial relationships as evidenced by increased communication among hospital staff and faith leaders when patients are nearing the end of their lives. We will track these advances qualitatively at the start, through discussions with hospital social workers and chaplains. Again, please note that coaching by the IHI Project Team is available to Community teams, and that aims can be adapted as initial work progresses and the focus of the work comes into greater clarity. Our goal is to help and empower you in your local environment, and to provide both tools and support to help you craft a project aim that is aligned with your health care organization s mission. ACTION ITEM: To set the direction for your aims, answer the key questions in the Project Aims Worksheet in the prework packet (Appendix A). Sample answers for each question are provided to give you an example of project aims. Organizational Background Assessment and Chart Audit We would like to learn about your organization, specifically about the type of data that is collected in your organization, preferred improvement methodologies, and prior improvement work in this content area. The questions should be answered by your project team. We recommend convening your team now, knowing that it will likely grow and evolve, to complete this prework together perhaps over a shared meal. ACTION ITEM: Please complete the Organizational Background Assessment and Chart Audit in the prework packet (Appendix A). Extranet Registration Day-to-Day Leaders (Key Contacts): Day-to-Day Leaders serve as the key contacts for the Conversation Ready Health Care Community. In order to facilitate communication among participating sites, IHI has developed a project Extranet for all members of the Community. Through the Extranet, you will be able to: View shared documents within the Community; Submit reports for your site; and Automatically register for the Community email list (listserv). Institute for Healthcare Improvement ihi.org 13

IHI will enroll all Day-to-Day Leaders in the Extranet. To do so, we first need all Day-to-Day Leaders to create a profile on IHI.org by following the steps below. (These steps are only necessary if you don t already have an IHI.org profile.) 1. Go to www.ihi.org, click Log In/Register at the top of the page, then click Register Now. 2. Enter all of the required contact information. 3. Choose a password that you will use to access the Extranet (case sensitive). 4. Click on the Complete Registration button. ACTION ITEM: Ensure your organization s Day-t0-Day Leader has a registered profile on IHI.org. Extranet registration will follow once IHI has the name of your Day-to-Day Leader/Key Contact from your prework submission. Team Photo In order to build relationships and facilitate networking in a mostly virtual environment, we would like a photo of your team to display during calls and in-person meetings. ACTION ITEM: Please submit a photo with your prework packet to IHI Project Coordinator, Aka Kovacikova, at akovacikova@ihi.org. Institute for Healthcare Improvement ihi.org 14

Appendix A: Prework Packet 1.0 Project Team Contact Information In the grid below, list the names, roles, and contact information of the individuals that will be part of your project team. The individual who has been designated the Day-to-Day Leader, who also serves as the Key Contact for the team, will be responsible for submitting monthly data reports and will receive all Community information from IHI to ensure streamlined communication. The Day-to-Day Leader will be responsible for sharing all Community information with his or her team. Core Team Name & Credentials Job Title Email Phone Day-to-Day Leader (Key Contact) Senior Leader/Sponsor Technical Expert(s) IT/IS Member(s) Patient(s)/Family Member(s) Other Team Member(s) 2.0 Focus Population and Pilot Setting Worksheet 1. We recommend that you focus your initial Conversation Ready work on a subpopulation of patients for which there is no argument about the need to better align patient and family wishes for end-of-life care with the care actually delivered. To that end, please identify a subpopulation. Institute for Healthcare Improvement ihi.org 15

2. For the subpopulation, identify one relevant formal document (e.g., Advance Care Plan, POLST, etc.) that should be part of the documentation of What Matters Most for recording end-of-life care wishes. 3. Describe what your organization does now to capture patient and family statements about What Matters Most for end-of-life wishes that are not contained in formal documents (e.g., free text in Progress Notes in the medical record). 3.0 Project Aims Worksheet Each team will set an aim for their work in this Community. It can be helpful to set a long-term overarching aim, as well as a short-term aim for your team s work over the nine-month Community. This secondary, short-term aim should represent the work that will help you achieve your team s overarching aim. An aim is an explicit statement summarizing what your team hopes to achieve during participation in the Community. It helps to focus on specific actions to improve patient care and outcomes, and to define which patients and providers will participate. Your team's aim should also be timespecific, measurable, and reflect a level of ambition that is a stretch and matches the capabilities and resources of the team. Please draft a beginning aim, which your team will further develop and finalize at the first Learning Session. Institute for Healthcare Improvement ihi.org 16

4.0 Organizational Background Assessment and Chart Audit Organizational Background Assessment The questions below will help us learn more about your organization and the capabilities that each organization can contribute to the Conversation Ready Health Care Community. Please briefly answer each of the following questions. 1. Provide a brief description of your organization, your patient population, and your catchment area. 2. Why did you decide to join the Conversation Ready Health Care Community? 3. What do you hope to get out of the experience? 4. What are the current strategic priorities for your organization, as determined by your leadership? Institute for Healthcare Improvement ihi.org 17

5. Do you have other initiatives currently underway that are related to advance care planning, promoting conversations about end-of-life wishes, improving end-of-life care, and/or development of palliative care expertise? If yes, please list and briefly describe each initiative. 6. Using the same topic list as in question #5, do you have prior initiatives related to these subjects? If yes, what are key lessons that you need to carry forward into this work from those initiatives? 7. Do you have a particular improvement method(s) that you use within your organization? If yes, what is it/what are they (e.g., Model for Improvement/PDSA, Lean, Six Sigma)? 8. Does anyone on your team have experience with using the Model for Improvement (using PDSA cycles for iterative tests of change)? If so, what was the context? Institute for Healthcare Improvement ihi.org 18

9. What is your current level, as an organization, of patient and family engagement in improvement efforts? Do you have a Patient and Family Advisory Council or similar body? 10. Looking back, what has been your most successful improvement effort? Why was it successful? What made it successful? 11. Looking back, what has been your least successful improvement effort? What did you learn from that experience? What would you do more of, better, and/or differently if starting over today? 12. What would be the best thing you could hear from a family when asked about their loved one s experience at the end of his/her life? Institute for Healthcare Improvement ihi.org 19

Chart Audit This next exercise is based on the presumption that you can access information related to the deaths of the population that you serve. If this is not the case, please be in touch with IHI so that we can help you adapt the exercise to be meaningful in your setting. Please review the records of the last 20 patients who died in your setting. As you review the charts, look for and note evidence of advance directives (not that they were just noted to exist, but that they could be accessed and understood), documentation of provider and patient conversation(s) about end-of-life wishes (or with surrogate decision maker, if patient not able to participate), the location of death, whether patient received heroic treatment measures, what were the circumstances of the death, and alignment of wishes with care received. For each patient record attribute reviewed, please quantify what you learned from this audit. For example: 65% of patient records reviewed had accessible advance directives; 50% of records had documented provider and patient discussions about end-of-life wishes; and, of patients for whom there was documentation of directives/end-of-life wishes, 55% had care plans that aligned with those wishes. Please share two stories gleaned from audit. For example: Mr. S had a note that an advance directive existed, but it was not accessible in the patient record. There was no documentation of a goals-of-care discussion, and the care team was not able to determine alignment of care goals and end-of-life wishes. Mrs. W had an accessible advance directive, detailed goals-of-care note in her patient record, and was transferred to inpatient hospice unit in alignment with her wishes. Institute for Healthcare Improvement ihi.org 20

Please answer these four questions after completing audit. 1. What surprised you the most about this exercise? 2. Based on what you learned, which aspects of your current system are most reliable? 3. Based on what you learned, which aspects of your current system are least reliable? 4. Does this exercise inform your focus for participating in the Conversation Ready Health Care Community? If yes, how? Institute for Healthcare Improvement ihi.org 21

Appendix B: Attributes of Highly Effective Teams Attributes of Highly Effective Teams Highly effective teams don t just happen! Time, cultivation, and attention are needed to create an environment for high-functioning teams. A short list of attributes of highly effective teams follows. The purpose and objectives of the team are clear. The roles of team members are clear. A cultural climate exists that seeks and supports participation of all team members. A cultural climate exists that supports problem solving and learning. Decision-making processes are clear. Leaders model a clear conflict resolution process. The team practices good housekeeping: clear agendas, start and stop times, role assignments (facilitator, note taker, timekeeper). Leadership is distributed and shared among team members. Team members strengths are utilized to the fullest. The team encourages risk taking and creativity. The team checks in about how they are functioning as a team. Activities to Help Form a Highly Effective Team The following recommendations come from conversations with several successful teams involved in IHI s Perinatal Care Improvement Community. We asked them, What makes a team gel? (We define gelling as sharing the same goals or vision, agreeing on the processes to implement to meet team goals, communicating openly, learning from data, and getting quality improvement results.) Setting Goals: Align your team s goals with your organization s overall aims. Make certain team goals are clear and relevant to both individual team members and the team as a whole. Begin each team meeting by reviewing the team s progress toward goals. Keep the goals and how to meet them as the team s primary focus. Relationship Building: Plan an off-site outing or potluck in the first few weeks of launching your improvement project. Break down the day-to-day barriers of the workplace and get to know your team members as individuals rather than just by their job roles. Learn the details of each team member s job responsibilities. This will help the team understand each other s perspectives, constraints, and strengths. Institute for Healthcare Improvement ihi.org 22

Take steps to share news about (and get recognition for) your team s work. For example, offer a lunch-and-learn on your early successes or contribute to your organization s newsletter. Data Collection: Combine storytelling with your data to engage both the heads and hearts of others. Institute for Healthcare Improvement ihi.org 23

Appendix C: IHI Project Team and Faculty IHI Team Kelly McCutcheon Adams, MSW, LISCW Director kmccutcheonadams@ihi.org Kevin Little Improvement Advisor klittle@iecodesign.com Angela Zambeaux Project Manager azambeaux@ihi.org Aka Kovacikova Project Coordinator akovacikova@ihi.org IHI Faculty Lachlan Forrow, MD Director of Ethics and Palliative Care Programs Beth Israel Deaconess Medical Center Kate Lally, MD Hospice Medical Director VNA of Care New England Jessica McCannon, MD Physician Massachusetts General Hospital VJ Periyakoil, MD Chief Associate Professor of Medicine Stanford University School of Medicine Donna Smith, MD Medical Director Virginia Mason Medical Center Institute for Healthcare Improvement ihi.org 24

CONGRATULATIONS! YOU HAVE COMPLETED THE PREWORK FOR THE CONVERSATION READY HEALTH CARE COMMUNITY. PLEASE SUBMIT THE DOCUMENTS LISTED ABOVE TO IHI PROJECT COORDINATOR, AKA KOVACIKOVA, AT AKOVACIKOVA@IHI.ORG BY FEBRUARY 3, 2014. COMPLETED PREWORK PACKET (APPENDIX A) TEAM PHOTO References 1 Heyland DK, Barwich D, Pichora D, et al. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med. 2013;173(9):778-787. 2 Strong Public Support for Right to Die. Pew Research Center, Washington, D.C. (January 5, 2006). http://www.peoplepress.org/2006/01/05/strong-public-support-for-right-to-die. Accessed on December 19, 2013. 3 The Conversation Project. Press release about recent survey results. September 18, 2013. http://theconversationproject.org/wp-content/uploads/2013/09/tcp-survey-release_final-9-18-13.pdf 4 Pattison M, Romer AL. Improving care through the end of life: Launching a primary care clinic-based program. J Palliat Med. 2001;4:249-254. 5 Norton SA, Hogan LA, Holloway RG, Temkin-Greener H, Buckley MJ, Quill TE. Proactive palliative care in the medical intensive care unit: Effects on length of stay for selected high-risk patients. Crit Care Med. 2007;35(6):1530-1535. Institute for Healthcare Improvement ihi.org 25