Dr. Marie S, Gustin Nursing Excellence Conference, 2012 The greatest difficulty in the world is not for people to accept new ideas but to get them to forget their old ones. John Maynard Keynes
Chaos, Complexity, and Change Quantum Leadership for a Transforming Health System Tim Porter-O Grady, DM, EdD, ScD(h), APRN, FAAN, FACCWS
Rule # 1 You MUST have a sense of humor
Tipping Point..
Complexity and Quantum Science Fractals Chaos Emergent mathamatics Self-organizing systems 2 nd Law of Thermodynamics (entropy) Scaling (r x X x 1 X = X nvr ) 4.6 10 Verhulst & Mandelbrot
C o n t e x t Innovation Environment Role Safe Intersection Evidence Dynami cquantum Medicine Agency Partnership Nursing CMS RWJ Accountable Care User E n g a g e m e n t
The 4 Rivers of Health Transformation From volume to value economics Models of accountable care (continuum) Interdisciplinary team decision/action User-driven technology
Catalyst
Leading Life at the Intersection Social networks Process networks Evidentiary networks Interdisciplinary networks Interfacing service networks
Don t Manage People Create context Manage movement Manage relationships Manage interactions Manage intersections Manage noise Create goodness-of-fit
No more top down : Definitions In complexity, order emerges from interacting agents and their interaction with the environment Order is not imposed exogenously Therefore, leadership is not only top-down, it is multi-lateral when interacting agents act as catalysts of center-out emergent structures & organizing patterns
Not Just Top-Down: Insights Lets us see different forms of leadership not restricted to formal (managerial) roles process that emerges center out a complex interactive dynamic (often informal) embedded in context Entanglement this informal, emergent leadership interacts with administrative (managerial, bureaucratic) leadership in a manner we call entanglement
INNOVATE!!
Essential Innovation Imagination Mental Models Innovation New Patterns Creative Thinking Skills Passion Rewards Outcomes Environment Knowledge Technical Value-based Conceptual Capacity Contribution
Innovation & Complexity Leadership Conceptual model of innovation based on interactions and complexity leadership Interactions are basic unit in complex system dynamics Specific interaction patterns can help to nurture innovation Generative leadership directs and manages interactions to maintain balance or edge of chaos
Innovation & Complexity Leadership Enabling innovation requires: Increasing interactions & introducing novelty Managing complexity Generative leaders nurture innovation by focusing on: Manipulating rules of collaboration Catalyzing the context Changing the system-environment model
Innovation and complexity leadership A model of generative leadership: Leveraging internal and external interactions Predictive Model Internal Organizations Team A Team B Team C Rapid Iteration & Feedback Environmental Opportunity External Organizations ExtOrg 1 ExtOrg 2 ExtOrg 3 Team N ExtOrg M Figure 3. Innovation dynamics leverage internal and external interactions to match predictive models to opportunities via rapid interaction and feedback
New 21 st Century Leader Skills Quantum leader skills Willingness Setting the table (gathering) Tough love language Confronting dependencies Leading movement Storytelling the journey Transferring skills for practice Making the journey safe
New Language Of Leadership Vulnerability to the risks Predictive / adaptive to flow Intuition and good translation Empathy with struggles of the collective Care about the work of healthcare Constant learning, not charisma Alignment not motivation
Centerpieces of the Next Steps Collaboration Information Integration The role of the nurse is to coordinate, integrate, and facilitate the stakeholders in the health journey
Higher Levels Of Role Satisfaction High Quality Patient Care Clinical Autonomy And Responsibility Effective Use of All Resources Interdisciplinary Integration C T C C Continuous learning Clinicallydriven Decision- Making
The only way to keep your health is to eat what you don't want, drink what you don't like, and do what you'd druther not. -Mark Twain
Accountable Care Organizations Collection of primary care physicians, hospital(s), specialists, NPs, and other health professionals that accept joint responsibility for the quality and costs of care provided to its patients and share in savings Establishes voluntary program beginning in 2012 where groups of qualifying providers (including hospitals) could take a leadership role in forming ACOs and share in Medicare cost savings Hospitals and Physicians (at minimum) working together to manage total patient cost of care and outcomes Providers enter into 3-year contracts with government Allows payment models beyond fee-for-service Spending below their benchmark eligible for shared savings Saves $4.9B over 10 years
Accountable Care Organizations Medical groups with 5000 Medicare lives may apply in 2014 Hospital participation not required Savings from reduced costs will be shared with ACO Creates incentives for physicians to manage care and benefit from the savings Best if hospitals and physicians learn to work together to control costs and produce better outcomes What implications will this create for how hospitals and physicians work together to care for a community
Implications for Hospitals and Doctors Hospitals must change the way care is delivered by moving to bigger episodes of care coordinated across the continuum and/or managing population outcomes Hospitals will need to build Network of physicians, NPs, Providers Potentially integrate community of providers IT and data management infrastructure Reimbursement infrastructure Create payer/provider partnerships Align internal incentive arrangements Measure and communicate results ACO management capability Define and drive improvement in population measures of success Legal and governance structure Central medical management capability Build patient centric, value oriented culture of continuous improvement
Who is eligible to be an ACO? ACO professionals in group practice arrangements Networks of individual practices of ACO professionals (through contractual affiliation) Partnerships or joint venture arrangements between hospitals and ACO professionals (contractual or organizational) Hospitals employing ACO professionals Such other groups of providers of services and suppliers as the Secretary deems appropriate.
Medicare Shared Savings Program ACO defined as: groups of providers of services and suppliers meeting criteria specified by the Secretary may work to manage and coordinate care for Medicare fee-for-service beneficiaries through an accountable care organization (referred to in this section as an ACO ) Many more specifics 2013,2014, 2015 Emerging acceptance by Health Plans
Building a Successful ACO Know your costs and utilization issues Build physician/nurse leadership and understand Utilization Management and Chronic Disease management systems that can reduce costs and increase health outcomes Integrated Electronic Medical Record with community wide integration and coordination Understand your community health profile and how you can delivered care in the past Patient-Centered Medical Home structure Financial models and quality/performance/evidence metrics Become a real health center
Payment To ACOs Payments will continue to be made to providers of services and suppliers participating in ACOs under Medicare s FFS Program for Parts A & B ACO is entitled to receive payment for shared savings if it meets certain requirements: Quality performance standards established by the Secretary Reporting requirements Benchmark target
Care Transformation Model Clinical Systems Patient & Family Personal Health Record Patient Portal Health Risk Assessment Patient Engagement & Activation Population Health Impact
Nurses Role Assess Onboard Link Document Continuum
Care Transformation Model Clinical Systems Advanced Primary Care Under Patient-Centered Health Home Prevention & Wellness Point of Care Analytics & Clinical Decision Support Gaps in Care Population Management & Chronic Care Registries Home Visiting Teams Generic Prescribing Program Cost Effective Medical Management & Utilization of Services (SCP, Ancillary) Access, Same Day Appointments, e-visits Patient Satisfaction & Loyalty Provider & Office Staff Satisfaction Patient & Family Personal Health Record Patient Portal Health Risk Assessment Patient Engagement & Activation
Nurses Role Prevention Primary care Counseling Referral Outcome Continuum
Care Transformation Model Operational Systems and Structure Advanced Primary Care Under Patient-Centered Health Home Point of Care Analytics Role Charters Additional Staffing (Providers) Work Flow Redesign & Process Changes Education of Staff, PCPs, Team Measurement Sets, Dashboards Patient & Family Value Based Benefit Design Benefit Design to Steer Patients Enrollment in Model (Attribution) Engagement Adequate Primary Care Base Financial Modeling
Care Transformation Model Clinical Systems Care management (Acute, Chronic, Inpatient, SNF) Health Coaching (Shared Decision Making) Medical Group & Health Care System Enterprise Level Activities PCP/SCP Incentives & Clinical Guidelines Pay for Value/Outcomes Initiatives & Impact Measurements Hospitalists, Post Discharge Follow-Up Programs Advanced Primary Care Under Patient-Centered Health Home Prevention & Wellness Point of Care Analytics & Clinical Decision Support Gaps in Care Population Management & Chronic Care Registries Home Visiting Teams Generic Prescribing Program Patient & Family Personal Health Record Patient Portal Health Risk Assessment Patient Engagement & Activation ER Avoidance Programs Urgent Care End of Life (Palliative Care) Patient Satisfaction & Loyalty Cost Effective Medical Management & Utilization of Services (SCP, Ancillary) Access, Same Day Appointments, e-visits Patient Satisfaction & Loyalty Provider & Office Staff Satisfaction Transition of Care Provider Satisfaction Behavioral & Mental Health
Nurses Role Coordination Interdisciplinary Partners Evidence Outcome Impact
Care Transformation Model Operational Systems and Structure Network Development Contracts (PCP/SCP) Participation Criteria, Report Cards, Monitoring & Corrective Action Plans Health Care Team Education Medical Group & Health Care System Enterprise Level Activities Clinical Support Infrastructure for Care Management Teams & Programs IT Infrastructure (EHR, Care Management Platform Analytics Clinical Decision Support, E-Prescribing, Predictive Modeling Tools) Advanced Primary Care Under Patient-Centered Health Home Work Flow Redesign & Process Changes Education of Staff, PCPs, Team Measurement Sets, Dashboards Patient & Family Point of Care Analytics Job Descriptions Additional Staffing (Physician Extenders) Value Based Benefit Design Benefit Design to Steer Patients Enrollment in Model (Attribution) Engagement Adequate Primary Care Base Financial Modeling Financial Incentives Measurement Sets & Operational Tools Integration of Best Practice and Clinical Guidelines
Ancillary Services Free-Standing ASC & Diagnostic Testing Centers Home Care Home Safety Visits Post Discharge Visits Home Health Coordinator of Services Hospice Transitions (CHF, COPD, Frailty Syndrome, Dementia) Care Transformation Model Clinical Systems (Partnership) Skilled Nursing Facilities SNFists On-site Case Management Efficiency Rating Systems Preferred Facilities Accountable Care Organization Medical Groups & Health Care System Enterprise Level Activities PC-MH Functions Medical Group & Health Care System Enterprise Level Activities PCP/SCP Incentives & Clinical Guidelines Pay for Performance Initiatives and Outcomes Measurements Hospitalists, Post Discharge Follow-Up Programs Care management (Acute, Chronic, Inpatient, SNF) Health Coaching (Shared Decision Making) Advanced Primary Care Under Patient-Centered Medical Home Prevention & Wellness Point of Care Analytics & Clinical Decision Support Gaps in Care Population Management & Chronic Care Registries Home Visiting Teams Generic Prescribing Program Patient & Family Personal Health Record Patient Portal Health Risk Assessment Patient Engagement & Activation Hospitals Service Line Integration Medical Staff Alignment Incentives for Efficiency & Lean Six Sigma Quality (SCIP, Leap Frog) Safety ER Avoidance Programs Urgent Care End of Life (Palliative Care) Patient Satisfaction & Loyalty Cost Effective Medical Management & Utilization of Services (SCP, Ancillary) Access, Same Day Appointments, e-visits Patient Satisfaction & Loyalty Provider & Office Staff Satisfaction Outcomes & Evidence Based Medicine Call Coverage Consult Services (Stroke, STEMI) Transition of Care Provider Satisfaction Behavioral & Mental Health DME Integration & Oversight with Care Management
Nurses Role Clinical Model Seamless Effectiveness Metrics Community Health Impact sustain
Transformation Model Operational Systems and Structure Accountable Care Organization Medical Group Hospital Systemness & Network Development Medical Staff Alignment Governance & Legal Structure Financial Incentives & Alignment (Shared Savings, Bundled Payments, Partial Cap, Full Cap) Sales & Marketing Strategic Planning Contracting (Evaluate Ancillary Services; SNFs, Home Care) Facility Evaluation (ASCs) Network Development Contracts (PCP/SCP) Participation Criteria, Report Cards, Monitoring & Corrective Action Plans Health Care Team Education Medical Group & Health Care System Enterprise Level Activities Clinical Support Infrastructure for Care Management Teams & Programs IT Infrastructure (EHR, Care Management Platform Analytics Clinical Decision Support, E-Prescribing, Predictive Modeling Tools) Advanced Primary Care Under Patient-Centered Health Home Work Flow Redesign & Process Changes Education of Staff, PCPs, Team Measurement Sets, Dashboards Patient & Family Point of Care Analytics Job Descriptions Additional Staffing (Physician Extenders) Financial Modeling Value Based Benefit Design Benefit Design to Steer Patients Enrollment in Model (Attribution) Engagement Measurement Sets & Targets Adequate Primary Care Base Health Plan Role for Incentives, Payment Models and Data Exchange Financial Incentives Measurement Sets & Operational Tools Integration of Best Practice and Clinical Guidelines
Accountable Care Systems Clinical Performance Operational systems Patient Focus II. Measurement Algorithms/Metrics V. Structures for Support/Payment User-driven Service III. Data Continuity/Sharing VI. Partner Models VII. Patient Engagement/Investment/ Continuity IV. Clinical Service Models IX. Governance & Leadership VIII. Sustaining the Service X. Health Information Infrastructure
New Model of 21 st Century Health Capacity Tools Connection Control User Centered Population-based Health Prescriptive Sustained / Safe Resource Sensitive Socio-political Priority 21 st Century Practice Competence Health Mobility/Synthesis/Access Inter-disciplinary Early Engage/Facilitate Techno-Clinical Genomics Virtual / Telecom Pharma/Nano Mobile