23 IU Health North Core Maxims • Take ownership-I choose to be responsible for my actions, attitudes and decisions. • Create joy-I have the power to be positive and lift the spirits of those around me. • Do more-I will look for ways to surprise my patients by doing more than they expect.
What We Say • Build and use your influence • Bob Waller’s 8 x 8 • Stories of impact • Listening with curiosity • “Above the line”
“Key ideas drive cultural change. For every important message, I deliver it 8 ways, 8 times.” - Dr. Robert Waller, CEO Emeritus, Mayo Clinic
27 To Be Happy, Be Curious • James Ryan’s Five Questions: 1. “ Wait, what?” – understanding 2. “I wonder…” – curiosity 3. “Couldn’t we at least…” – mobilize 4. “How can I help?” – asking is key 5. “What truly matters?” Source: Mineo , Liz. “Want to be Happy? Be curious.” Harvard Gazette. 14 Apr. 2017.
28
Humility
New Quality (and Safety) Paradigm Old way New way Quality is about compliance. Quality is about continuous, systematic improvement. Quality is a function of governance. Quality is a shared responsibility. Data is for assessment. Data is for rapid adjustment. Power is concentrated (in the hands of the Power is distributed to patients and staff at checkers). the point of care. Leadership creates standards. Leadership creates culture.
Listen to Understand – Not to Respond “Wide lugs and a short tongue is best” Scottish Proverb
Ask and Listen: Heroism is Out, Humility is In!
Schein on Culture • Culture is a result of what an organization has learned from dealing with problems and organizing itself internally • Your culture always helps and hinders problem solving • Culture is a group phenomenon • Don’t focus on culture because it can be a bottomless pit. Instead, get groups involved in solving problems
What We See • “Real” rounds • Journey of a patient through a time of care • Spaghetti diagrams • Commensality
Source: Ron Bialek, Grace L. Duffy, and John W. Moran, The Public Health Quality Improvement Handbook (Milwaukee, WI: ASQ Quality Press, 2009), page 220.
Cede Power
“For every complex problem there is an answer that is clear, simple, and wrong." H. L. Mencken
Getting to the Third Curve Ceding power Sharing power MOBILISING SOCIAL ACTION Outcomes Keeping power QUALITY IMPROVEMENT NEW PUBLIC MANAGEMENT Targets, CO-PRODUCING sanctions, QUALITY IMPROVEMENT inspections PERFORMANCE MANAGEMENT Time
Create Ability
Psychology of Change AGENCY The ability of an individual or group to choose to act with purpose Power Courage The ability to The emotional resources to choose to act act with purpose Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement . Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology
IHI Psychology of Change Framework Unleash Intrinsic Motivation Tapping into sources of intrinsic motivation galvanizes people’s individual and collective commitment to act. Co-Design People- Adapt in Action Driven Change Acting can be a motivational experience Those most affected by for people to learn and change have the greatest iterate to be effective. interest in designing it in Activate ways that are meaningful and workable to them . People’s z z Agency Co-Produce in Distribute Power Authentic Relationship People can contribute their unique assets to Change is co-produced when bring about change people inquire, listen, see, and when power is shared. commit to one another. Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement . Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology
Joy in Learning
What do these have in common? NASA Challenger BP Gulf Spill Mid Staffs NHS
The Cycle of Fear 45 Increase Fear Kill the Micromanage Messenger Filter the Information
Personal Resilience
Networks
53 From Ideas to Action • Flow across the system • Waste and cost • Safe care • Joy in work • Patient-centered redesign
54 Achieving Hospital-Wide Patient Flow http://www.ihi.org/communities/blogs/why-hospital-flow-is-key-to-patient-safety
55 Does every hospital admission need a root cause analysis? • “No fault hospitalization” • Preventable with traditional medical care • Preventable with attention and intervention in social determinants • Medical error • Flow problems • Staffing challenges • Communication and handovers Source: Mark Depman, NJEM Catalyst, October 18, 2017
56 A New Way • Engineered and designed flow • Upstreamism • Outplacing • Partnering in care
57 16-Bed MICU: “We need more beds!” Source: Bela Patel, MD and Khalid Almoosa, MD
58 “We have plenty of ICU beds!” • VAP/ BSI rates Zero - $54,000/$ 35,000 • EC- ICU 53% to 75% in 4 hours • Hospital LOS decreased 1.5 days $$ • Floor codes decreased 50% • End of Life – ICU stay – decreased 3.3 days • Mortality decreased by 13%, CMI up 15%, • Occupancy decreased from 94.5% to 85.5% • Monthly admissions: from 89.4 to 104.6 • $5.1 Million saved Source: Bela Patel, MD and Khalid Almoosa, MD
# of Patients with a New # of Patients with a New Patients who Utilize an ICU bed b/c an Appropriate Failure Failure 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 7/16/2… 7/16/2008 10/14/… 10/14/2… 1/12/2… Delayed or Canceled Surgery Due to Bed 1/12/2009 4/12/2… 4/12/2009 7/11/2… 7/11/2009 10/9/2… 10/9/2009 1/7/2010 1/7/2010 4/7/2010 4/7/2010 7/6/2010 7/6/2010 10/4/2… 10/4/2010 Bed is Not Available 1/2/2011 1/2/2011 4/2/2011 4/2/2011 7/1/2011 7/1/2011 9/29/2… 9/29/2011 12/28/… 12/28/2… Capacity 3/27/2… 3/27/2012 6/25/2… 6/25/2012 9/23/2… 9/23/2012 12/22/… 12/22/2… 3/22/2… 3/22/2013 6/20/2… 6/20/2013 9/18/2… 9/18/2013 Daily Critical Flow Failures 12/17/… 12/17/2… 3/17/2… 3/17/2014 6/15/2… 6/15/2014 9/13/2… 9/13/2014 12/12/… 12/12/2… 3/12/2… 3/12/2015 6/10/2… 6/10/2015 9/8/2015 9/8/2015 12/7/2… 12/7/2015 3/6/2016 3/6/2016 6/4/2016 6/4/2016 9/2/2016 9/2/2016 12/1/2… 12/1/2016 3/1/2017 3/1/2017 5/30/2… 5/30/2017 8/28/2… 8/28/2017 # of Patients with a New # of Patients with a New 10 12 Failure Failure 0 2 4 6 8 0 1 2 3 4 5 6 7 8 9 7/16/2008 7/16/2008 Psychiatry Patients Placed Outside of their 10/14/2… 10/14/2… 1/12/2009 1/12/2009 4/12/2009 4/12/2009 PICU Bed Not Available for Urgent Use 7/11/2009 7/11/2009 10/9/2009 10/9/2009 1/7/2010 1/7/2010 4/7/2010 4/7/2010 7/6/2010 7/6/2010 10/4/2010 10/4/2010 1/2/2011 1/2/2011 4/2/2011 4/2/2011 7/1/2011 7/1/2011 Primary Unit 9/29/2011 9/29/2011 12/28/2… 12/28/2… for Health Systems Excellence James M. Anderson Center 3/27/2012 3/27/2012 6/25/2012 6/25/2012 9/23/2012 9/23/2012 12/22/2… 12/22/2… 3/22/2013 3/22/2013 6/20/2013 6/20/2013 9/18/2013 9/18/2013 12/17/2… 12/17/2… 3/17/2014 3/17/2014 6/15/2014 6/15/2014 9/13/2014 9/13/2014 12/12/2… 12/12/2… 3/12/2015 3/12/2015 6/10/2015 6/10/2015 9/8/2015 9/8/2015 12/7/2015 12/7/2015 3/6/2016 3/6/2016 6/4/2016 6/4/2016 9/2/2016 9/2/2016 12/1/2016 12/1/2016 3/1/2017 3/1/2017 5/30/2017 5/30/2017 8/28/2017 8/28/2017
James M. Anderson Center for Health Systems Excellence System Wide Patient Flow Delays
Telehealth at Cincinnati Children’s Provider Outpatient Inpatient Diagnostic Testing Conferences Consultations Consultations Remote Patient Common to Additional Virtual Monitoring Complex- ECHO Patient Care Model Confidential proprietary information of Cincinnati Children’s Hospital Medical Center. Do not distribute.
Patient Flow| Operational Control Center
Patient Flow| Accelerator Program ER Registratio Care Medical MDA Medical n staff Practice Patient Flow Surgical Scheduling Pre Units Surgery Support Readmissions Admission Center Decrease length of stay and the virtual beds gain 4.10 3.96 3.87 3.86 3.81 3.75 3.64 3.51 3.40 3.28 34 20 36 44 54 74 97 117 147 Length of stay Virtual gain capacity (beds) The reduction in LOS provided a capacity gain equivalent to 147 virtual beds
64 Flow • What innovations have you implemented? What works and what doesn’t? • Do you need new roles? • What delays and complications can you improve? • What leadership driver do you most need to enhance?
65 Eliminate Waste and Managing Value • “Seeing” waste • Adding value • Equipping staff
Reducing Harm, Waste and Variation
Reduce Waste “ 50%of all resource expenditure in hospitals is quality- associated waste” - recovering from preventable foul-ups - building unused or unusable products - providing unnecessary treatment - simple inefficiency Brent James and Lucy Savitz – Intermountain Healthcare
68 “See” the Waste
69 Trillion Dollar Checkbook 1. Reduce harm & safety events 2. Reduce non-value added operational workplace waste 3. Reduce non-value added clinical workplace waste 4. Solicit staff and clinician ideas 5. Involve patients in identifying what matters most 6. Redesign care to achieve Triple Aim
70
BUILDING ON THE WEDGES OF WASTE (Hackbarth/Berwick): REDUCING THE BAG OF $ - A Starting Checkbook for Big & Smaller US Healthcare Waste (starting list - Helen Macfie & Jim Leo) - DRAFT Primary Drivers / BOLD Goal Relative Ease Savings Goes To: Average Avoidable Cost per Instance Avoidable Volume, USA Lower Bound Total $$ (CxD) Upper Bound Total $$ Definitions/Notes Overall Approach/Ideas Barriers and Obstacles to Plan For Waste Opportunity Priority Billions (C x D) Billions P1: Reduce Harm & Safety Events Infections - reduce hospital Reduce Infections of 5 HAIs by 40%. Note: "EASY" PROVIDER: $5.5 billion SSI = $20,786/case, CLABSI = $45,814/case, 65% of CLABSI cases, 55% of VAP cases, $4.60 $6.50 IHI/Published cost savings/infection type Toolkits (existing) Renewed attention acquired Focus on CLABSI, VAP, SSI, CAUTI, CDI. CAUTI = $896/case, VAP = $40,144, CDI = 26% of SSI cases, 50% CDI cases, and IHI Campaign, renewed $11285/case 70% of CAUTI cases Local systems/design Sepsis Reduce Cost by 25% Note: not "EASY" PROVIDER Sepsis attributable hopsital costs at index 20-25% reduction in sepsis cost/case $4.50 $5.60 Surgical v non-surgical patients with Toolkits (surviving sepsis) IHI Renewed attention; Community Partnerships published but MemorialCare has reduced hospitalization and 90 days post discharge: Note: we have not yet quantified sepsis "Campaign", renewed direct variable cost from $28K/case to $32,900/pt surgical, $5,800/pt nonsurgical. impact of reducing actual cases coming Local systems/design $22K/case (21%) for severe sepsis and in from the community Community education - earlier septic shock cases, while reducing recognition mortality by 55% for patients who are not DNR within first 24 hours of hospital care. Improve Medication Focus: Improve clinical Medication MEDIUM PAYOR Between $10,100 and $14,200 in payments 27% reduction in all-cause readmission $14.50 $20.30 Improve "good" reconciliation within 48- Uniform criteria needed Provider resources Reconciliation and Reducing Reconciliation across Continuum of Care to per readmission rate after implementation of 72 hours of transfer to alternate level of Standardized approach needed Systems/documentation (EHR records) Readmission "90"% medication reconciliation program care (focus on home first) Opioid Use Reduction Reduce Dispensed Opioids by "20-40"% MEDIUM PROVIDER $4,006 per opioid poisoning event (includes 22% reduction in morphine milligram $12.20 $19.40 Reduce prescriptions - both # of Rx and Provider education to reduce # and Current supply Ex: Reduce opioid Rx for opiate-naïve ED, OP, ambulatory, and nalaxone costs) ----- equivalents (MME) per person (Oregon quantity per Rx quantity Provider buy-in patients at discharge or new outpatient Rx --------------------------------$15,935 all-cause Health Authority) with associated 38% Reporting for MME ordered to <7 day supply (if they need it at all. medical cost differential per patient reduction in poisoning events ----------- Note: Does not include reduced cost from between 1 year before initial opioid ---------------------------------------- 11% avoided opioid dependence with precription and 1 year post initial precription of 8 million chronic opioid users that associated chronic care costs (excluding (among chronic opioid users) received potentially innapropriate overdose). prescription Overdiagnosis Reduce Cost to Top 5-10 Diagnoses by 25% HARD PAYOR $345 per mammogram; $6283 per CKD case; Assumed 25% reduction across all $67.80 $67.80 Overdiagnosis: pick top 5 or 10 Advocacy - NNTH/B, publication bias Belief, Inertia (breast cancer screening, pre diabetes, ckd, $2560 per hypertension case; $511 per pre- cases/tests diagnoses; assume 25% reduction; find Education; Campaign asthma, hypertension, CDI) diabetes case; $4166 per asthma case, $750 average cost of treatment Local systems/design (drug costs) per CDI case (claims data)
What is Muda? • Muda ( 無駄 ) is a Japanese term for anything that is wasteful and doesn't add value. It is also a key concept in the Toyota Production System. Waste reduction is an effective way to increase profitability. • A process adds value by producing goods or providing a service. A process also consumes resources. Waste occurs when more resources are consumed than are necessary to produce the goods or provide the service.
Do you A Framework to Continuously have a Improve Value by Reducing standard care Cost & Improving Quality Yes model? 3. Leadership No 2. Optimize Decision Efficiency 1. Standardize Making Model Track the costs of the care Map Process process Key Concepts • Simplification • Coordination Understand Reduce waste, • Substitution variation improve • Improved performance decision-making Redesign process Is staff engagement high? IHI R&D, 2016 Is quality high and Check Continuously: What is the impact on job consistent? satisfaction?
74 Hamad Medical Corporation – 9 teams Initial Pilot First spread units Second spread phase Heart Heart Six Hospital: Hospital: additional teams in Cardiac Cardiac four sites step-down ICU + imaging
75 Results, cont. Overtime cost (RNs) Measure 16000 Improved 14000 UCL scheduling 12000 10000 8000 6000 4000 LCL 2000 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
76 Waste • Do you have a means to “see” waste in your system? • How are you balancing top-down versus bottom-up solutions? • How can you further build the will for change here? • What leadership driver do you most need to enhance?
77 Safe Care • Understanding safety performance now and improving • Seeing diagnostic error • Looking across the system
Diagnostic Errors • Affect 1 in 20 adults • Leading cause of malpractice claims – 29% of total suits from 1986-2010 • Leads to delays in treatment and increases cost of care Source: https://www.modernhealthcare.com/article/20190126/NEWS/190129972/coalition-tackling-diagnostic-errors-gains-some- traction
79 Six Barriers to Accurate Diagnosis 1. Poor communication during care transitions 2. Lack of measures and feedback 3. Limited support to help with clinical reasoning 4. Limited time 5. It’s complicated 6. Lack of funding for research Source: The Society to Improve Diagnosis in Medicine. https://www.improvediagnosis.org/new_posts/40-healthcare-organizations- launch-unprecedented-effort-to-improve-accuracy-and-timeliness-of-diagnosis/
80 Increased Fall Risk • Number of fall related ED visits by people 65+ increased by 38% in California between 2010 and 2015 • Fall related medical costs total more than $31 billion each year nationally • Problem will be further exacerbated as baby boomers age Source: Gorman, Anna. "ER Visits Linked To Falls Spike Among California Seniors." California Healthline. 15 Feb. 2017.
81 CAPABLE • “Community Aging in Place, Advancing Better Living for Elders” – Emphasizes helping older adults maintain independence through environmental adaptations and interventions – Team of nurse, occupational therapist, and handyman • Common fixes: – Installing or fixing railings or grab bars – Improving lighting – Installing non-skid treads in tubs and showers – Repairing trip hazards, like holes or tears in carpet, or broken times • 79% of initial participants reported fewer activity of daily living limitations Source: Szanton, S.L., Wolff, J.L., Leff, B., Roberts, L., Thorpe, R.J., Tanner, E.K., Boyd, C.M., Xue, Q.L., Guralnik, J., Bishai, D., Gitlin, L.N.: Preliminary data from community aging in place, advancing better living for elders, a patient-directed, team-based intervention to improve physical function and decrease nursing home utilization: the first 100 individuals to complete a centers for medicare and medicaid services innovation project. J. Am. Geriatr. Soc. 63(2), 371 – 374 (2015).
82 CAPABLE • Roughly $3,000 in program costs yields approximately $10,000 in savings in medical costs. • Participants showed reduced symptoms of depression, fewer difficulties with Activities of Daily Living, and improved motivation. Source: Szanton, S.L., Wolff, J.L., Leff, B., Roberts, L., Thorpe, R.J., Tanner, E.K., Boyd, C.M., Xue, Q.L., Guralnik, J., Bishai, D., Gitlin, L.N.: Preliminary data from community aging in place, advancing better living for elders, a patient-directed, team-based intervention to improve physical function and decrease nursing home utilization: the first 100 individuals to complete a centers for medicare and medicaid services innovation project. J. Am. Geriatr. Soc. 63(2), 371 – 374 (2015).
How do you “see” harm in hospital 85 care? • Do you have a dosing formula and a method to share best performance quickly and to all? • Have you shared the story (like Gilbert), the extrapolation, the human cost, and the financial cost? • Can you measure harm across the system? • What’s the leadership driver you most need to enhance?
Deming and Joy in Work “Management’s overall aim should be to create a system in which everybody may take joy in his work.” – Dr. W. Edwards Deming
The Burning Platform 87 Source: www.nam.edu/perspectives
Measurement
IHI Organizational Diagnostic
92 Joy in Work • Have you used your data to predict and plan for a vibrant workforce? • How are you doing on psychological safety, meaning, sense of control and recognition? • How are you building effective teams and creating cameraderie? • Which of the leadership drivers are most relevant here?
93 New Ways to Codesign Care with Patients and Families
Patient-Centered Redesign – Self Dialysis • Self-dialysis transformation began in 2005 at Ryhov Hospital in Jönköping, Sweden • Christian asked about doing his own dialysis, then taught another patient, and the program grew • Now 70% of dialysis patients at the hospital perform their own treatments • Self-dialysis is performed at 50% of costs of other hemo-dialysis units
95 Waco, Texas • Patients were taught to self-administer care at the CTNA clinic • In 2016, almost 40 % of CTNA’s 751 patients performed their own dialysis • They also experienced fewer hospitalizations and a lower mortality rate • Staff burden shifted from performing each step of dialysis to serving as coaches and supporters of patients performing self-care Source: https://hbr.org/2017/06/the-value-of-teaching-patients-to-administer-their-own-care
My Dialysis, My Choice The patient starts by selecting a few values that matter most to them when choosing a treatment plan Then detailed information is provided to help the patient rate treatment options according to how well they match each chosen value Source: mydialysischoice.org
My Dialysis, My Choice Based on the patient’s rankings on each value, the results are compiled to help them decide which dialysis treatment option is best for their lives and health Source: mydialysischoice.org
98 Royal Free Hospital, London “Maximising kindness and friendship towards patients through systematic staff development, environmental design and clinical practice .”
99 Key Results • Unit length of stay reduced by 2.6 bed days • 26% reduction in readmissions • 49 % of patients initially labelled as ‘now needs nursing home’ converted to ‘return to their previous home’
June 4, 2014
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