Transcript IHI: The Way We Work Royal Colleges Study Tour 23 October

WELCOME
An Introduction to IHI
Penny Carver
Senior Vice President
Carnegie Foundation
Knowledge Alliance Working Meeting
January 20, 2010
IHI Mission
The Institute for Healthcare Improvement
is a not-for-profit organization driving the
improvement of health by advancing the
quality and value of health care.
Why We Exist
“Between the health care we have
and the care we could have lies
not just a gap, but a chasm.”
- Institute of Medicine, Crossing the Quality Chasm, 2001
Defects….for example…
• 45% of needed care is not received
• 22% of chronically ill adults report a “serious error”
in their care
• 74% of chronically ill adults say the system needs
“fundamental change” or “complete rebuilding”
• Case-mix adjusted hospital death rates vary 400%
• Resource use in the last six months of life varies
>500% among 77 top-rated US hospitals
• Per capita annual health care costs:
─ US: ~$6000
─ Sweden: ~$2800
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Variation in Practice
Hysterectomy by
age 70
Prostatectomy by
age 85
70
60
50
40
30
20
10
0
Maine
Main
Maine
Iowa
Iowa
hospital hospital hospital hospital
International Comparison of Spending
on Health, 1980–2005
Average spending on health
per capita ($US PPP*)
Total expenditures on health
as percent of GDP
* PPP=Purchasing Power Parity.
Data: OECD Health Data 2007, Version 10/2007.
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6
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
Is there an achievement gap
in education?
Our Blueprint: the IOM’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
We Do This By…
• Building the will for change
• Cultivate promising improvement
ideas
• Putting those ideas into action
through effective execution
“Improvement of any system requires will,
ideas and execution.”
- Tom Nolan, PhD
Institute for Healthcare Improvement
2010 IHI Strategic Plan
WHO WE ARE
We are a reliable source of energy, knowledge, and support for a never-ending campaign to improve health and health care worldwide.
WHAT WE WILL ACCOMPLISH
In the US and abroad, we will improve the lives of patients, the health of communities, and the joy of the health care workforce, and reduce health
care costs. We work with health care providers and others to accelerate the measurable and continual progress of health care systems throughout the
world toward Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity.
WHAT WE WILL BECOME
We will be a recognized and generous leader, a trustworthy partner, and the first place to turn for expertise, help, and
encouragement for anyone, anywhere who wants to change health care fundamentally for the better.
Strategy #1: Motivate
Strategy #2: Innovate
Strategy #3: Get Results
Stimulate the desire and
optimism for change
Create, find and test
new models of care
Ensure wide adoption of sound
changes
A. Publicize widely the case for
improvement, promising
designs and impressive results
B. Publish widely in peerreviewed journals
C. Ally with influential
organizations that share our
aims to amplify our
effectiveness
D. Influence the national health
policy debate
A. Discover health care
processes and
systems that will
deliver better
outcomes and lower
costs
B. Demonstrate the
efficacy of new models
and codify content in
preparation for spread
A. Convene and manage vibrant
networks, communities and
partnerships to deploy proven
changes rapidly
B. Disseminate health care
improvement ideas and methods
through world-class learning events
C. Create and expand a world-class
web presence to propel the spread
and adoption of improvements at
very low cost
Strategy #4: Raise Joy in
Work
Help build a better health
care workforce
A. Ensure that young health
professionals are prepared
for effective participation in
improvement
B. Ensure that executives,
boards, and relevant public
officials are prepared to
support improvement
C. Develop and nurture a
cadre of improvement
leaders
Strategy #5: Stay Vital for the Long
Haul
A. Continually improve IHI’s leadership C. Maintain a sound operating margin,
system and plan for succession
continually reduce overhead costs
Sustain IHI’s viability
B. Make IHI the best place to work in theD. Raise funds reliably to help support
eyes of its employees and faculty
unfunded community benefits
How We Change the World
The Technical Approach
The First Law of Improvement
“Every System Is
Perfectly Designed
to Achieve Exactly
the Results It Gets”
(Therefore, although not all change is
improvement, all improvement Is change)
Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in an
improvement?
Act
Plan
Study
Do
Repeated Use of the Cycles
DATA
Hunches
Theories
Ideas
A P
S D
A P
S D
A P
S D
A P
S D
Changes that
Result in
Improvement
Multiple PDSA Cycle Ramps
Triage
Diagnostic
Fast Track
Testing
Patients
Change Concepts
Capacity/
Demanding
Applying the Model for
Improvement to Education
The Social System
Breakthrough Series
Collaboratives
The Breakthrough Series
Select
Topic
Participants
Prework
Change
Concepts
Printed Reports
P
P
A
D
A
S
LS 1
D
S
LS 2
National
LS 3
Expert
Group
Supports
E-mail Visits
Phone Documents
Assessments
Congress
Where is the Project?
Successful changes
High
Degree of
belief that the
changes will
result in
improvement
Changes still need
further testing.
There is a risk of
moving to spread
Moderate
Unsuccessful
proposed changes
Low
Prototype
Pilot
Spread
Pursuing Perfection
An IHI program funded by The Robert Wood Johnson
Foundation to improve patient outcomes dramatically by
pursuing perfection in all of the major care processes.
Pursuing perfection means striving to:
• Deliver all indicated services at the right time;
• Avoid services that are not helpful to the patient or
reasonably cost effective;
• Avoid safety hazards and errors that harm patients
and employees; and
• Respect patients’ unique needs and preferences.
January 2001-April 2006
Unnecessary Hospital Deaths:
Developing a Learning System
• Do people die unnecessarily every single day in
our hospitals?
• In order for us to understand this, we need a
diagnostic journey that moves out of a model for
judgment and into a model for learning.
• New model:
- What can we learn from the deaths?
- Was perfect care given?
• You need to get a clearer understanding of local
conditions that contribute to mortality.
IHI Approach to Mortality Reduction
Comfort Care
Non Comfort Care
ICU Admission
No ICU Admission
86/3175
3%
(0-14%)
402/3175
13%
(0-40%)
1161/3175
37%
(10-72%)
1526/3175
48%
(18-76%)
Areas of Improvement That We
are Focusing On
• Box 3 Changes (ICU)
─Ventilator Bundle
─Central Line Bundle
─Multidisciplinary Rounds/Shared Goal Sheet
─Glycemic Control
─Sepsis Bundle and detection
─Appropriate tidal volume for ARDS/Acute
Lung Injury patients - very early work for us
Areas of Improvement That We
are Focusing On
• Box 4 Changes (non-ICU)
─ Rapid Response Team
─ Improved communication
 SBAR
 Shift handoffs
─ Early Warning System
─ Multidisciplinary Rounds outside the ICU
─ Glycemic Control outside of ICU
─ Crew Resource Management Training
The “100,000 Lives Campaign”
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The Campaign “Planks” -Six Changes That Save Lives
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•
•
•
•
•
Deployment of Rapid Response Teams
Delivery of Reliable, Evidence-Based
Care for Acute Myocardial Infarction
Medication Reconciliation
Prevention of Central Line Infections
Prevention of Surgical Site Infections
Prevention of Ventilator-Associated
Pneumonias
Six Additional Planks
• Prevent Pressure Ulcers
• Reduce Methicillin-Resistant Staphylococcus
Aureus (MRSA) Infection
• Prevent Harm from High-Alert Medications
• Reduce Surgical Complications (the Surgical
Care Improvement Project (SCIP))
• Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure
• Get Boards on Board
IHI Programs
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•
•
•
•
The Improvement Map
WIHI
STAAR
Safer Patients Network
Scottish Patient Safety
Programme (SPSP)
•
•
•
•
Triple Aim
How Do They Do That?
R&D
The IHI Open School
• Builds on the great work of participants in the 100,000 Lives
Campaign and the 5 Million Lives Campaign.
• “Help us make sense of the many complex and competing demands
we face.”
• Brings together the best knowledge available on the key process
improvements that will lead to exceptional hospital care.
• Helps hospital leaders set change agendas, establish priorities,
organize work, and optimize resources.
• An open resource, available free of charge to anyone, anywhere.
• Launched on September 15, 2009.
Safer Patients Initiative
An IHI Program Funded by The Health Foundation
• The 100,000 Lives Campaign
was built around 6 interventions
• The Safer Patients Initiative
combined 5 of the “Campaign 6”
plus 10 other change elements
• Phase 1: Four acute hospital
trusts – Wales, Northern Ireland,
England, and Scotland
Safer Patients Initiative
Multiple “Centers of Gravity”
• The SPI change package addresses five clinical
areas:
- Medicines management
- Infection prevention and control
- Peri-operative care
- Critical care
- Care on general wards
• All supported by an organisational wide effort to bring
about a change in culture working at all levels but
with a key role for senior leaders
Safer Patients Initiative
Safer Patients
Initiative 2
Driver Diagram
Primary Drivers
Leadership
System for Safety
.
Improve
healthcare safety
on an
organisation-wide
basis by reducing:
1. Mortality by 15%
2. Adverse events
by 30%
Care of Critically
Ill Patients
Secondary Drivers
Safety as a Strategic Priority
Sustainable Infrastructure
Engaged and Committed Leadership
Ventilator Associated Pneumonia
(Reduce to 0 or 300 Days Between)
Central Line Bloodstream Infections
(Reduce to 0 or 300 Days Between)
Blood sugars within Range (80% or >)
Perioperative
Care Management
Surgical Site Infections - clean
(Reduce by 50%)
Care of General
Ward Patients
Crash Call Rates
(Reduce by 30%)
MRSA Bloodstream Infections
(Reduce by 50%)
Medicines
Management
Anticoagulant Adverse Drug Events
(Reduce by 50%)
The “Triple Aim”
• Improve Individual Experience
• Improve Population Health
• Control Inflation of Per Capita Costs
The root of the problem in health care is that the business
models of almost all US health care organizations depend on
keeping these three aims separate. Society on the other hand
needs these three aims optimized (given appropriate
weightings on the components) simultaneously.
--- (Tom Nolan, PhD)
How Do They Do That
Low-Cost, High-Quality Care
• July 21, 2009: Meeting in Washington, DC with Don
Berwick, Elliott Fisher, Atul Gawande and Mark
McClellan
• Involving health care leaders from a select group of highperforming regions of the U.S. to share their experiences
• Sponsored by the Institute for Healthcare Improvement,
The Dartmouth Institute for Health Policy and Clinical
Practice, the Harvard School of Public Health, and the
Engelberg Center for Health Care Reform at The
Brookings Institution
Much has been learned
Price-adjusted per-capita Medicare spending 2006
$10,250 to 17,184
9,500 to < 10,250
8,750 to < 9,500
8,000 to < 8,750
6,039 to < 8,000
Not Populated
(55)
(69)
(64)
(53)
(65)
Hope
90-Day Project Topics
November 2009-Janurary 2010
Hospital Projects
•
•
•
•
•
Waste Reduction Tool
Financial Implications for Hospitals of Reduce Readmissions
Learning from Specialty Care and ED Use Prototyping
Work Place Safety Program Development
Other Hospital Waste and Cost Reduction Projects as needed
Triple Aim Projects
• Triple Aim in a Region
• Improvement at a Country Level
• Connecting and Activating Community Health Care and Other
Resources
• Socially Complex Patients
The IHI Open School Mission
“Advance health care improvement
and patient safety competencies
in the next generation of health
professionals worldwide.”
The IHI Open School
Curriculum
Content
Social
Networks
Experiential
Learning
Progress
• Registration
─ Over 20,000 students registered on IHI.org
─ Over 6,000 faculty and deans registered on IHI.org
• Online courses
─ Over 20,000 courses completed (50% students, 50% professionals)
─ Available: 6 Quality Improvement, 3 Patient Safety, 1 Leadership
• Online Resources
─ Over 30,000 downloads of case studies, glossaries, exercises, activities
─ Over 58,000 downloads of audio and video recordings
• Online Community
─ YouTube, Facebook, Blog, Twitter
IHI Open School Chapters
173
Chapters
173 Chapters on 185 campuses
119 US Chapters in 40 states
54 International Chapters in 24 countries
Experiential Learning
• Projects initiated by students
─WHO Surgical Checklist Student Project
• Projects initiated by faculty
─Beverly Hospital Chapter
• Projects initiated by the IHI Open
School team
─Shadowing students of another health profession
So Where Will IHI Lead?
• To meet the challenge of moving the “big
dots”
• To create new, more effective designs
• To ensure deep results and broad reach
• To restore joy and confident capability
IHI Staff
IHI Values
Cooperation and Boundarylessness
Our culture is team-oriented, and we all learn from and teach each other. We
are an organization without walls that welcomes members of our team who are
not based in Boston to be fully included in and informed about our day-to-day
work.
Patient and Health Care Focus
We focus our energies primarily on content areas that will improve the lives of
patients.
Speed and Agility
We anticipate customer needs and develop solutions that address those needs
quickly and efficiently.
Customer Focus
We anticipate customer needs and develop programs that address those needs
quickly and efficiently. We will know we have succeeded when customers can
measure results and value from our interactions.
IHI Values
Valuing Volunteers
We will continually delight the faculty and associates with whom we work.
Honesty and Transparency
We will be honest and open about our successes and failures, and will thereby
be worthy of trust.
Orderliness
We will continuously improve our leadership and management by developing
innovative processes and eliminating waste.
Celebration and Thankfulness
We celebrate our work and thank publicly and privately those that bring about
our successes.