Transcript All-Teach, All-Learn: Pathways to the Triple Aim

Leading Together
UT System Clinical Safety and Effectiveness Conference
October 27, 2011
Maureen Bisognano
President and CEO
IHI
Aims for Today
• Look out at the challenges we share in the
coming year
• Look around for ideas and models
• Look in and celebrate the amazing work
you are doing
Our Challenges
• Structural challenges in this time
of reform
• Health needs and challenges in the
populations we serve
• Managing the complexity in caring for
patients
Making Sense of It All
Scores: Dimensions of a High Performance Health System
75
73
70
Healthy Lives
70
71
Quality
2006 revised
2008 revised
2011
75 *
67
Access
57
55
52
53
53 *
Efficiency
69
71
69
Equity
67
65
64
OVERALL SCORE
0
100
* Note: Includes indicator(s) not available in earlier years.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
5
HEALTHY LIVES
Mortality Amenable to Health Care
Deaths per 100,000 population*
1997–98
150
2006–07
134
127
116
115
109
99
100
89
88
120
113
106
97
97
88
81
76
50
96
57
55
61
60
61
64
66
74
67
76
79
78
77
80
83
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* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.
See Appendix B for list of all conditions considered amenable to health care in the analysis.
Data: E. Nolte, RAND Europe, and M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health
Organization mortality files and CDC mortality data for U.S. (Nolte and McKee, 2011).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
6
HEALTHY LIVES
Infant Mortality Rate
Infant deaths per 1,000 live births
National average and state distribution
U.S. average
12
Top 10% states
11.1
10.3
8
Bottom 10% states
7.2
7.0
International comparison, 2007
10.8
10.2 9.9
9.9
9.6
6.9
7.0
6.8
6.8
10.1
6.8
10.0 9.9
6.9
6.7
6.8
6.8
5.1
4
5.3
5.1
4.0
5.0
4.9
4.8
4.7
4.7
5.0
5.0
5.0
2.0
2.5
2.6
2.7
3.1
20
07
20
06
20
05
^
20
04
20
03
^
20
02
20
01
20
00
19
99
19
98
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^ Denotes years in 2006 and 2008 National Scorecards.
Data: National and state—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003–2008; Mathews
and MacDorman, 2011); international comparison—OECD Health Data 2011 (database), Version 06/2011.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
7
QUALITY: EFFECTIVE CARE
Hospitals: Prevention of Surgical Complications
Percent of adult surgical patients who received appropriate care to prevent complications*
2004
98
100
87
2006
97
93
2009
96
94
89
83
81
74
71
75
90
66
59
49
50
25
0
90th % ile
75th % ile
Median
25th % ile
10th % ile
* See Appendix B for methods and description of clinical indicators.
Data: IPRO analysis of data from CMS Hospital Compare.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
8
QUALITY: COORDINATED CARE
Medications Reviewed When Discharged from the Hospital,
Among Sicker Adults, 2008
Percent of hospitalized patients with new prescription who reported
prior medications were reviewed at discharge
100
77
75
67
54
57
59
59
59
60
FRA
CAN
NETH
UK
AUS
50
25
0
NZ
US
GER
Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized
or had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands;
NZ=New Zealand; UK=United Kingdom; US=United States.
Data: 2008 Commonwealth Fund International Health Policy Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
9
QUALITY: SAFE CARE
Potentially Preventable Adverse Events and Complications of Care in Hospitals
Adjusted rate
per 1,000 discharges*
2002
2003
2004
2005
2006
2007
Failure to rescue
141.7
135.0
128.9
120.4
114.0
105.7
Decubitus ulcers
22.1
23.4
24.7
24.1
24.6
25.1
Selected infections because
of medical care
2.3
2.3
2.3
2.3
2.2
2.0
Postoperative pulmonary
embolus or deep vein
thrombosis
9.6
10.3
10.7
10.7
11.2
11.5
Postoperative sepsis
11.1
11.7
13.2
13.7
15.1
15.4
* Rates are adjusted by age, gender, age-gender interactions, comorbidities, and Diagnosis Related Group (DRG) clusters.
Data: Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (retrieved from HCUPNet at http://hcupnet.ahrq.gov).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
10
10
QUALITY: PATIENT-CENTERED, TIMELY CARE
Difficulty Getting Care After Hours Without Going to
the Emergency Room, Among Sicker Adults, 2008
Percent of adults who sought care reported “very” or “somewhat” difficult to get care
on nights, weekends, or holidays without going to the emergency room
100
75
56
58
59
59
CAN
US
AUS
FRA
45
50
34
39
27
25
0
NETH
GER
NZ
UK
Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized or
had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New
Zealand; UK=United Kingdom; US=United States.
Data: 2008 Commonwealth Fund International Health Policy Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
11
Our Challenges
• Structural challenges in this time of
reform
• Health needs and challenges in the
populations we serve
• Managing the complexity in caring for
patients
Figure 1. Growth in the Number of People Age 65 and Older
450
404
Number (in millions)
400
377
325
300
227
200
50
0
12%
249
250
100
300
281
203
10%
179
150
76
92
4%
96%
1900
106
4%
96%
1910
123
5%
95%
1920
132
5%
95%
1930
20%
351
65+
Under 65
350
151
7%
93%
1940
11%
13%
21%
17%
20%
13%
9%
8%
92%
1950
91%
1960
90%
1970
89%
1980
87%
1990
88%
2000
87%
2010
84%
2020
80%
2030
79%
2040
80%
2050
Note: The total population data for 1900 to 2000 include unknown age data. Therefore, the data used to determine the proportion
of the population under age 65 and age 65 and older does not sum to equal the total population.
Sources: 1900 to 2000 data are from Hobbs, F., & Stoops, N. (2002). Demographic Trends in the 20th Century (Census
2000 Special Reports, CENSR-4). Washington, DC: U.S. Census Bureau. Available at
http://www.census.gov/prod/2002pubs/censr-4.pdf. 2010 to 2050 data are from Population Projections Program (2000).
Projections of the Resident Population by Age, Sex, Race, and Hispanic Origin: 1999 to 2100 (Middle Series).
Washington, DC: U.S. Census Bureau. Available at http://www.census.gov/population/www/projections/natdet.html.
Source: R. Friedland and L. Summer, Demography Is Not Destiny, Revisited, The Commonwealth Fund, March 2005.
THE
COMMONWEALTH
FUND
A Youth Bulge
• The world is in a demographic transition –
from high rates of fertility and mortality, to
lower birthrates and longer lives.
• But since mortality rates are falling before
fertility rates are, a “youth bulge” results.
• We need new designs to ensure the health
of these growing populations.
Southcentral Foundation, Anchorage, AK
The “Five Year
Gestation”
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults
BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults
BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults
BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults
BRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
Source: Behavioral Risk Factor Surveillance System, CDC.
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
Source: Behavioral Risk Factor Surveillance System, CDC.
25%–29%
≥30%
The “Hot Spots”
• “Super” utilizers of health services
• 5% of patients account for 49% of US
health spending
• Patients at the end of life need improved
palliative and hospice care
Our Challenges
• Structural challenges in this time of
reform
• Health needs and challenges in the
populations we serve
• Managing the complexity in caring
for patients
Increasing Complexity
• In the mid 1970s, the average patient in a
hospital required 2.5 staff FTEs for care…
• …20 years later, the average patient
needs 19.5 FTEs†
• A physician today has over 13,600
possible diagnostic options and the
opportunity to select from over 6000
prescription options in the US
†Source:
Atul Gawande, MD
The Path Forward
• New ways to lead
• Vibrant and important aims
• More ways to learn
The Four Leadership Questions
• Do you know how good you are?
• Do you know where you stand relative to
the best?
• Do you know where the variation exists?
• Do you know the rate of improvement over
time?
New Leadership Skills
Personal
Structural
Leading Through:
• Attention
• Listening
• Sensing
• Learning
• Action
• Signs and symbols
Leading With:
• Patient-led design
• Structural huddles
• Gemba walks
• Cultural changes
–
–
–
–
•
•
Safety
Harm
Patient-centered
Improvement and
innovation
Spread strategy
Building capability
Structured Huddles
• A huddle is a “communication vehicle…a fast,
focused, highly collaborative process.Ӡ
• Huddles should be frequent and short.
• They enhance communication; generate and
help manage knowledge; and help continuously
improve care delivery.
Robert L. Meara, ME. “The Organizational Huddle Process – Optimum Results Through
Collaboration.” Health Care Manager: December 2002.
†Cooper,
Huddles
at Cincinnati Children’s Hospital Medical Center
Gemba Walks
Ghana: Rapid scale-up of systems
improvement across nation’s health facilities
Project is ahead of
schedule, with
simultaneous
spread in northern
regions (NCHS
and Ghana Health
Service) and
middle regions
(NCHS hospitals
Collaborative).
The Path Forward
• New ways to lead
• Vibrant and important aims
• More ways to learn
Health of a
Population
Experience of
Care
Per Capita
Cost
Health of a
Population
Experience of
Care
Per Capita
Cost
Institute of Medicine’s Six Aims
• Safe – no needless deaths
• Effective – no needless pain or suffering
• Patient-Centered – no helplessness in
those served or serving
• Timely – no unwanted waiting
• Efficient – no waste
• Equitable – for all
Patient-Centered Flow
• Patient demand is growing
• Our ability to safely and efficiently
serve all patients depends on:
– Right Patient
– Right Place
– Right Time
– Right Care Team
– No Delays
• Most activity in the hospital is
scheduled; urgent/emergent work
is “predictable”
Flow and Safety
• Inseparable initiatives in a hospital
• Getting the “Rights” right
– Right Bed, Nursing Care, Time, Plan, Treatment
• No longer a passive system – best care requires
active management of these critical aspects of
the patients experience.
• Best route to optimize the best care model is to
control the variables in care delivery.
Initial Results of Re-Design
• Weekday Waiting Times – 28% reduction in spite of a 24%
increase in case volume
• Weekend Waiting Times – 34% reduction in spite of a 37%
increase in case volume
• Throughput increase of 4.8% = 1 OR room in a
setting of 20 rooms
• Overtime hours decreased by an estimated 57% between
September 18, 2006 and the first week of January 2007.
If OR operating costs are estimated at $250/room hour,
then these savings are equivalent to $10,750/week, or
$559,000 annually.
• Overall growth sustained at ~7% / year for past two
years, no additional operating rooms added
Greater Production Capacity Through
Flow and Patient Placement – What Has it Meant?
• Has allowed for an additional 78 patients per day to be
treated within our current bed capacity that would not
have been possible under “pre-flow improvement
processes
• Improved flow and patient placement have allowed us to
avoid the construction of 102 additional beds ($100+
million) that would have been required to meet today’s
volume in our FY2002 workflow system
Institute of Medicine’s Six Aims
• Safe – no needless deaths
• Effective – no needless pain or suffering
• Patient-Centered – no
helplessness in those served or
serving
• Timely – no unwanted waiting
• Efficient – no waste
• Equitable – for all
How do we make care more patient centered?
The Burden of the Illness
Innovation: Learning from Patients
The Old Way
• Ryhov Hospital in Jönköping had traditional hemodialysis
and peritoneal dialysis center.
• But in 2005, a patient, Christian, asked about doing it
himself.
The New Way
• Christian taught a 73-yr-old woman how to do
it…
• …and they started to teach others how to do it.
The New Way
• Now they aim to have 75% of patients to be on
self-dialysis
• They currently have 60% of patients
Lessons to Date
• From Christian (patient):
─“I have a new definition of health.”
─“I want to live a full life. I have more energy
and am complete.”
─“I learned and I taught the person next to me,
and next to her. The oldest patient on selfdialysis is 83 years old.”
─“Of course the care is safer in my hands.”
Lessons to Date
• From Anette (nurse leader):
─ Surprised at design differences between patients,
family, and staff
─ Managing at 1/2 – 1/3 less cost per patient
─ Evidence of better outcomes, lower costs, far fewer
complications and infections
─ “We brought in the county’s employment, helped the
patients make or update the CVs, and trained them
for a new career.”
Lessons to Date
• From Britt Mari (nurse and innovator):
─Found courage to say “yes” in the patient’s
face
─“We used the same training program as I use
for new nurses.”
─“The patients are our partners in designing
the unit, buying equipment, teaching, and
planning.”
Lessons to Date
• From Ingrid (nurse):
─“I got the courage to change (after 40 years)
because I saw the patients ‘lift up.’”
─“I moved from being a technical expert to a
coach.”
─“The patients are so fit, always exercising
while they treat.”
Health of a
Population
Experience of
Care
Per Capita
Cost
Henry Ford Health System
Total Harm-Associated Costs 2009*
Harm Issue
Pressure Ulcer stage 2 or higher
Total Associated Costs
$10,624,410
Coded Procedural Complication ICD9 (998-999.99)
UTI using coded data and AHRQ definition.
Glucose below 40
Coded Acute Renal failure
$7,670,520
$5,662,895
$3,846,375
$2,665,680
Coded DVT/PE in both medical and surgical patients
No Pulse Blue Alert
Coded Medication issue
Clostridium difficile infection
Reported Fall with injury
Bloodstream Infections using NHSN criteria
Coded Pneumothorax using AHRQ definition
SSI using NHSN criteria
VAP using NHSN criteria
$2,365,470
$1,535,808
$1,216,078
$824,544
$696,527
$640,000
$340,260
$280,000
$190,352
*Henry Ford Hospital Only
Removing Waste
• Dr. Patty Gabow at Denver Health, a
safety-net system, introduced a waste
reduction focus several years ago.
• Her team has reduced expenses there by
$71M, $30M in the last year – she said,
“We’re getting good at getting better.”
Waste Identification Tool
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/
HospitalInptWasteIDTool.htm
http://www.ihi.org/IHI/Results/WhitePapers/HospitalInpatientWasteIDTool
WhitePaper.htm
Health of a
Population
Experience of
Care
Per Capita
Cost
Ideal Collaboration
Between Patients and Providers
• The greatest, untapped resource for improving health
care is the knowledge, wisdom, and energy of the
individuals, families, and communities who face
challenging health issues in their every day lives.
• People must be engaged as co-producers of health care
for themselves and their communities, not merely as
patients or consumers of services.
• Local communities must retrieve their own historical,
cultural, and religious traditions of health and healing,
and bring those into dialogue with contemporary medical
systems.
-Bill Doherty
University of Minnesota
Jönköping County
Obesity Initiative
Walking bus
School nurse
Dentist
Nutritionist
Salutogenesis
Aaron Antonovsky
From the Latin “salus” which means
health, and the Greek “genesis” which
means origin.
A “health-ease” instead of a “dis-ease”
continuum
The Path Forward
• New ways to lead
• Vibrant and important aims
• More ways to learn
Live Case Visits
• Powerful tool for showing the gap between
current performance and the best
• Visitors study an exemplar’s (host’s) processes
from the inside
─ Interview staff
─ Reflect on challenges they face at their home
organizations, ask the hosts how they have overcome
barriers to change
Live Case Visits
• Visitors regroup and plan their strategy for the
return home
• Visitors then meet with hosts at the end of the
visit to reflect on what they observed, and how
this informs their strategy for their organization
• Hosts offer advice, guidance, and feedback on
visitors’ strategy
Live Case Visits
IHI Open School
IHI Open School Chapter Community
365
Chapters
US Chapters in 46 states
International Chapters in 50 countries
IHI Open School Measures
• 68,000 students and residents registered on IHI.org
• 9,000 faculty and deans registered on IHI.org
• 27,000 students and residents have completed an
online course
• 1,900 students and residents have earned their
Certificate of Completion
* Since the IHI Open School was created in September 2008
Celebrating Success
in the UT System
•
•
•
•
•
Reliable processes with great tempo
Physician engagement
Multidisciplinary teamwork
Financial connections
Progress!
Promising Improvements
in the UT System
• Improved patient access at MD-Anderson’s
Neuro-Interventional Ultrasound (NIR)
─Average time to next appointment decreased
from over 25 days to 1 day
─Available appointment slots increased from 38
to 55
Promising Improvements
in the UT System
• Decreasing duration of mechanical
ventilation at Parkland Health and Hospital
system
─Mean duration of mechanical ventilation in the
MICU decreased from 6.1 days to 4.0 days
─Ventilator-associated pneumonia rate reduced
by 52%
Promising Improvements
in the UT System
• Reducing avoidable harm in the medical
ICU at UT Southwestern University
Hospitals Dallas
─Health care-associated infections (HAIs) fell
from 63 in 2009; to 32 in 2010; and to 21 as of
August, 2011
─Patient falls with injury eliminated in MICU
Thank You!
Maureen Bisognano
President and CEO
Institute for Healthcare Improvement
www.IHI.org
[email protected]
617-301-4800