Transcript Time Magazine: How to Fix the System

Improving Quality in Practice.
Approaching Improvement in a
Complex System
SPICE and Service
Improvement Methodology
Jonathon Gray
Director Healthcare Improvement
Wales Centre for Health
PARIS
IN THE
THE SPRING
PARIS
IN THE
THE SPRING
How many legs does this elephant have?
The First Law Of Healthcare
Improvement
“Every system is
perfectly designed to
achieve exactly the
results it gets”
Therefore, Although Not All Change Is
Improvement, All Improvement Is
Change
Source: Don Berwick, IHI (Boston)
Welsh Policy Context
 2003
Wales: A Better Country
• Where are we going?
 2005
Designed for Life
• What do we need?
 2005
Healthcare Standards for Wales
• What do we do?
 2006 The Healthcare Quality
Improvement Plan: Designed to Deliver
• How will we get there?
Aims for Improvement
“By 2015, Wales will have minimized
avoidable deaths, pain, delays,
helplessness, and waste.”
Designed for Life
Safety
Effectiveness
Patient Experience
Timeliness
Efficiency
“The needs of the patient come
first…..”
No needless deaths
No needless pain or suffering
No unwanted waiting
No helplessness
No waste
……For anyone
What do we need to measure and
why?
IHI Model for Improvement
CAUTION!
Gathering data
can bring new
and surprising
knowledge to
those who
dare to seek it!
How Hazardous Is Health
Care?
DANGEROUS
(>1/1000)
Total lives lost per year
100,000
REGULATED
ULTRA-SAFE
(<1/100K)
HealthCare
Driving
10,000
1,000
Scheduled
Airlines
100
Mountain
Climbing
Bungee
Jumping
10
Chemical
Manufacturing
Chartered
Flights
European
Railroads
Nuclear
Power
1
1
10
100
1,000
10,000
100,000
Number of encounters for each fatality
1,000,000 10,000,000
Hospital Death Rate
(Standardized for Age, Sex, Race, Payer, Admission Source & Type)
vs Charge per Admission
Standardized Death Rate
(Standardized for Age and Diagnosis) -- AHRQ 1997 Data
180
160
140
120
100
80
60
40
20
0
0
5,000
10,000
15,000
20,000
Standardized Charge ($ per Admission)
25,000
Organisation with a Memory
 15,000 to 70,000 adverse events each year in the
Wales NHS hospital sector (10 - 40% of
admissions)
 £100 million direct cost in additional hospital days
alone
 Clinical negligence cost - £85m (2004-05)
 Half might be avoidable.
Source: Organisation with a memory - CMO England)
Essential Elements for LargeScale Change
• Will
• Ideas
• Execution
We will explore new ways of working, recognising that there may now
be better and different methods
The Knowledge Base
for Continual Improvement
Subject and
Discipline
Knowledge
Knowledge for
Improvement
+
Continual
Improvement




Systems
Variation
Psychology
PDSA
The Project Method: The Model
for Improvement (Nolan, et al.)
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 Cycle
Changes That
Result in
Improvement
A P
S D
A P
S D
Hunches
Theories
Ideas
Leadership
-Topic is a key strategic initiative
-Goals and incentives aligned
-Executive sponsor assigned
-Day-to-day managers identified
Measurement and Feedback
Set-up
Better Ideas
-Develop the case
-Describe the ideas
-Target population
-Adopter audiences
-Successful sites
-Key partners
-Initial spread strategy
Knowledge Management
Social System
-Key messengers
-Communities
-Technical support
-Transition issues
Acknowledgements: Improving Chronic Illness Care, a national program of The Robert Wood Johnson Foundation
Components of an Improvement
System
STRATEGY
--Leadership
--System Aims
--Finance
--Training
--Environment
MANAGING
IMPROVEMENT
TECHNIQUE
CULTURE
--Statistics and Measurement
--Systems Knowledge
--Group Process
--PDSA
--Tools
--Teamwork
--Cooperation
--Operating Values
--Beliefs and Myths
Justin
Justin Micalizzi
(by Dale Ann Micalizzi)
• “On January 15th, 2001, Justin, a
healthy 11-year old boy, was taken into
surgery to incise and drain a swollen
ankle. He was dead by 7:55 a.m. the
next morning, leaving behind two
grieving and bewildered parents who
desperately wanted to know why their
son had died. But medical care was to
fail them twice- first their son died and
then no one would explain to them
why.”
Justin Micalizzi
(by Dale Ann Micalizzi)
• I know the chaos, the nursing shortages, overtime, the
financial obligations, the insurance company guidelines
and the arrogance that interferes with the quality of care. I
have worked in healthcare and education for over 20
years. I also know, when it came time for my son’s
surgery, you remove the chaos. You develop a team effort
to review all information and establish a plan. You openly
communicate between specialists, remove arrogance and
intimidation and have a common goal to heal. It is your
obligation to complete checklists, check and double check
medications and dosages, assign a nursing team and treat
every case as a possible emergency with the patient as
your ONLY focus. Look at the child; listen to the parents
and use common sense and professional judgment when
making all decisions. Slow down! You are holding my
child’s life in your hands. Justin WAS important and
should have been important to his healthcare providers
also. I trusted you.
Justin Micalizzi
(by Dale Ann Micalizzi)
• The hospital failed us, the nurses who were his
advocates failed us, and the technicians who
didn’t draw pre-op labs failed us. And, most
importantly, the surgeon who gave the case to
the resident and was NOT even in the OR at the
time of surgery failed us. The health department
failed us by accepting the medical personnel’s
information as truthful. The hospital CEO failed
us by not providing us with any information or
support. Error upon accepted error killed my
son and my faith in a medical system that was
meant to comfort and heal. We will not let this
happen to another family. The pain is
unbearable.
Justin Micalizzi
(by Dale Ann Micalizzi)
“….. when it came time for my
son’s surgery, you remove
the chaos……”
The Simple, Wrong Answer
Blame
Somebody
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)