Transcript Sustainability and Building Quality into Systems

Sustainability and Building
Quality into Systems
Donald M. Berwick, MD, MPP
Institute for Healthcare Improvement
1000 Lives Campaign Plenary Session
30 September 2009
Swansea, Wales
My Topics
•
•
•
•
•
Looking Backward – to 2007
The Current Environment
A Global View
Quality and Cost in the New Economy
Where Next for Wales?
My 2007 Advice
1. Declare patient injuries an enemy,
and establish patient safety as a
shared goal.
2. Cease blame. Substitute science.
3. Assess where you are starting.
4. Collaborate with other nations to
pursue “Shared Aims.”
4
My 2007 Advice
5. Establish knowledge exchange, and
increase peer-to-peer learning
6. Foster a community of expertise –
Faculty for Quality Improvement
and “Health Care Improvement
Fellows”
7. Reconvene annually to review,
reflect, learn and celebrate.
5
Today’s Environment
•
•
•
•
Global Financial Crisis
Dominant Concern about Health Care Costs
Governments under Intense Scrutiny
Restructuring
6
An International Movement of
Movements?
The Entire UK Is Engaged
8
England
• Cause
– To make the safety of patients
everyone’s highest priority
• Aim
– No avoidable death and no
avoidable harm
• Interventions
– Leadership for safety
– Reducing harm from deterioration
– Reducing harm in critical care
– Reducing harm in perioperative
care
– Reducing harm from high risk
medicines
Scotland
• 5.5 million people
• Scottish Patient Safety
Programme
– 37 acute hospitals
 Critical care
 Peri-op
 Medicines
 General ward
 Leadership
• Aims
– 15% reduction in mortality
– 30% reduction in adverse
events
Denmark
•
•
•
5.5 million inhabitants
Health care is a public task
5 regions that are responsible for
health care
Operation Life:
• 38 hospital units
–
–
–
–
–
–
•
Rapid Response Systems
AMI Bundle
Medication Reconciliation
Ventilator Bundle
Central Line Bundle
Surviving Sepsis Campaign
Aims
–
Save 3000 lives during campaign
period
 All regions present at campaign start
 Cover 75% of discharges
www.operationlife.dk
11
Canada
• 33 million people
• 10 interventions + 2
pilots
• 1035 teams enrolled
• 80% of acute care
hospitals enrolled
• All regional health
organizations
outside of Quebec
enrolled
Aim
• Reduce adverse
events by 40-100%
dependent upon
intervention
www.saferhealthcarenow.ca
Japan
“PARTNERS for Patient Safety”
National Campaign for Patient Safety in Japan
http://kyodokodo.jp/
Wales
• 3 million people
• 1000 Lives Campaign
– All Hospitals, Primary Care
and Ambulance services




Leadership
Critical Care/Rapid response
Medicines
Healthcare associated
infection
 Surgical care
 General medical and surgical
care
• Aims
– To save 1000 lives, and
– Avoid 50,000 cases of harm
in 2 years from April 2008
www.1000livescampaign.wales.nhs.uk
Scottish Patient Safety Program
NHS Dumfries and Galloway
Royal Infirmary VAP Rate
Shift
Downward and
Sustained
Days between VAPs
• Glasgow and Clyde Board
– Glasgow Royal: 260 days
– IRH: 185
– SGH: 127
– GGH: 110
• Lothian (Edinburgh)
– Edinburgh Royal: 130 days
– SJH: 192
• Forth Valley
– Falkirk and Sterling Royal: 300
• Highland: 300 days then a VAP now back up to 180
NHS Dumfries and Galloway Royal Infirmary
Central Line Bloodstream Infection Rate
Only Two
Infections since
January 2008
Central Line infection RatesDays Since Last Infection
• Forth Valley- 554 days
• Fife Queen Margaret- 375 days
• Glasgow Royal- 49 days (got one after a
run of 245 days)
• Highlands- 180 days (was 360)
• Edinburgh Royal Infirmary- 98 days
• Aberdeen Royal Infirmary- 89 (was 150)
C. Difficile Associated Disease Rate
NHS Lothian
Shift
Downward and
Sustained
Quality and Cost
Does Improvement Help?
IHI’s Work on Cost & Quality
• Kano’s Three Levers
• Triple Aim
• “How Do They Do That?” Project
Noriaki Kano’s Three Levers for
Improving Value
1
Eliminate quality problems that
2
Reduce costs (waste) significantly
arise because customers’ (patients’) expectations
are not met
while maintaining or improving quality
3
Expand customers’ (patients’)
expectations by providing products and
services (care delivery) perceived as unusually
high in value
Noriaki Kano’s Three Levers for
Improving Value
Historic Focus in
Healthcare
1
Eliminate quality problems that arise because
customers’ (patients’) expectations are not met
2
Reduce costs (waste) significantly while
maintaining or improving quality
3
Expand customers’ (patients’) expectations by
providing products and services (care delivery)
perceived as unusually high in value
HIGH
VERY LOW
VERY HIGH
(Kano 1) Case Study
From Richard Shannon, MD, Chair-Department of Medicine
Hospital of the University of Pennsylvania
• 37 year old video game programmer, father of four,
admitted with acute pancreatitis
• Day 3: developed hypotension and respiratory failure
• Day 6 : fever and blood cultures positive for MRSA
secondary to a femoral vein catheter in place for four
days
• Multiple infectious complications requiring exploratory
laparotomy and tracheostomy
• Day 86: Discharged to nursing home
CCU/MICU and HAI
A Big Return on Investment
• Total Operating Improvements
CLAB= $1,235,765 (2 years)
VAP= $1,003,162 (1 year)
MRSA= $ 295,342 (1 year)
• Highmark PFP = $3,100,000 (2 years)
• HAI Elimination Initiatives = +$5,634,269
• Investment = $85,607
• 388 Additional ICU Admissions
• 57 Lives Saved
Noriaki Kano’s Three Levers for
Improving Value
Historic Focus in
Healthcare
1
Eliminate quality problems that arise because
customers’ (patients’) expectations are not met
2
Reduce costs (waste) significantly while
maintaining or improving quality
3
Expand customers’ (patients’) expectations by
providing products and services (care delivery)
perceived as unusually high in value
HIGH
VERY LOW
VERY HIGH
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.
Six Categories of Waste (Muda)
1. Delay: idle time spent waiting for something, such as utilization
reviews, insurer payments, test results, patient bed assignments,
OR prep, medical appointments.
2. Re-work: performing the same task a second time, such as retesting, re-scheduling, re-filing of lost claim forms, re-writing of
patient demographic data, multiple bed moves.
3. Overproduction: manufacturing of products or information
that is not needed, such as precautionary “defensive” medical
tests, surplus medications, excessive levels of paperwork.
Cont. 
Six Categories of Waste (Muda)
4. Movement: unnecessary transport of people, products or
information, such as requiring patients to see a primary care
provider before seeing a specialist who is clearly needed.
5. Defects: design of goods that do not meet customer needs,
such as medication errors, wrong side surgery, poor clinical
outcomes.
6. Waste of Spirit and Skill: failure to address the
many hassles in our daily work, hunting and gathering, re-calling,
the same things every day
How Big Is This Muda Problem?
• Estimates range as high as 40% of total
expenditures are adding no value to
patients or staff. For example:
– Patients may be transferred three to six times
during a four day length of stay
– Wastes include: time, supplies, medications,
information, even food.
From: The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-aLifetime Opportunity. Center for Health Design
Intermountain Healthcare:
Study of Caregivers’ Use of Time Suggests 50% Waste
Single observer
shadowed 61
caregivers for 72
hours
• 8 physicians
• 26 nurses (ICU,
Med/Surg,
recovery room)
• 8 others
• Less than 50% time
spent in productive
work
- 20% time clarifying
- 19% time processing/
documenting
- 17% time in motion
• Average of two
significant problems
encountered per hour
MUDA
• Estimated
minimum cost of
waste for one
shift on 46 bed,
26 staff medical
unit = $2300
• $8.80/hr x 12hrs x
26 staff x 50%
(waste)
Equivalent annual
cost = $1.6m per
ward
Waste Reduction Targets for
National Priorities
Partnership
50% Waste
Reduction
by 2015
*A partnership
between
the National Quality
Forum and 28Emergency
other organizations
• Preventable
Department
• Inappropriate
Medication
Use
Targeting inappropriate antibiotic use and polypharmacy (for
Visits and Hospitalizations
multiple chronic conditions; of antipsychotics).
• Unnecessary Laboratory Tests
Targeting panels (e.g., thyroid, SMA 20), special testing (e.g.,
Lyme Disease with regional considerations).
• Unwarranted Maternity Care
Interventions
Targeting unwarranted cesarean section.
• Unwarranted Diagnostic Procedures
Targeting cardiac computed tomography (non-invasive
coronary angiography and coronary calcium scoring), lumbar
spine MRI prior to conservative therapy, without red flags,
uncomplicated chest/thorax CT screening, bone or joint x-ray
prior to conservative therapy, without red flags, chest x-ray,
preoperative, on admission, or routine monitoring, endoscopy.
• Unwarranted Procedures
Targeting spine surgery, percutaneous transluminal coronary
angioplasty (PTCA)/Stent, knee/hip replacement, coronary
artery bypass graft (CABG), hysterectomy, prostatectomy.
• Unnecessary Consultations
Targeting potentially preventable emergency department visits,
hospital admissions lasting less than 24 hours, and ambulatory
care sensitive conditions.
• Inappropriate Non-Palliative Services
at End of life
Targeting chemotherapy in the last 14 days of life,
inappropriate interventional procedures, and more than one ED
visit in the last 30 days of life.
• Potentially Harmful Preventive
Services with No Benefit
Targeting BRCA mutation testing for breast and ovarian cancer
– female, low risk, CHD: Screening using ECG, ETT, EBCT –
adults, low risk, carotid artery stenosis screening – general
adult population, cervical cancer screening – female over 65,
average risk; female, post-hysterectomy, prostate cancer
screening – male over 75 (from the U.S. Preventive Services
Task Force D Recommendations List).
www.qualityforum.org
Noriaki Kano’s Three Levers for
Improving Value
Historic focus in healthcare
1
Eliminate quality problems that arise because
customers’ (patients’) expectations are not met
2
Reduce costs (waste) significantly while
maintaining or improving quality
3
Expand customers’ (patients’) expectations by
providing products and services (care delivery)
perceived as unusually high in value
HIGH
VERY LOW
VERY HIGH
University of Pittsburgh Medical Center
DiGioia A, Greenhouse P, Levison T. “Patient and Family-centered Collaborative Care: An
Orthopaedic Model”. Clinical Orthopaedics and Related Research. 2007: 463; pp: 13-19.
Aims in Redesigning Care for Patients Undergoing
Total Joint Replacement
1.
2.
3.
4.
5.
6.
7.
8.
Patient and family education
Less invasive techniques
Multimodal anesthesia and pain management techniques
Rapid rehabilitation protocols
Rapid outcomes feedback (from the patients’ and the
providers’ perspectives)
Creating a learning environment and culture
Developing a sense of community, competition and teamwork
among patients and between patients, caregivers and staff
Promoting a wellness (rather than sickness) approach to
recovery
University of Pittsburgh Medical Center
DiGioia A, Greenhouse P, Levison T. “Patient and Family-centered Collaborative Care: An
Orthopaedic Model”. Clinical Orthopaedics and Related Research. 2007: 463; pp: 13-19.
• New Designs:
– Pre-op Testing and Teaching
– Coaching Meetings with Other Patients
– Pre-surgery Discharge Planning
– Strong Focus on Complete Pain Management
– “Wellness” Design in Orthopedics Unit
UPMC Results
Safety
– Mortality rates: 0.1% (0.2% for TKA; 0% for THA)
– Infection rates: 0.3% (0% for TKA; 1.0% for THA)
– Zero dislocations
– SCIP compliance: 98% for antibiotics within one
hour of surgery
UPMC Results
Effectiveness
– 91% of patients discharged without handheld
assistance directly to home (national rates:
23-29%)
– 99% of patients reported that pain was not an
impediment to physical therapy, including
same-day-of-surgery physical therapy
UPMC Results
Patient-Centeredness
– Press-Ganey mean satisfaction score is 91.4% (99th
national percentile ranking) with 99.7% positive
responses to “Would you refer family and/or friends?”
Efficiency
– Average length of stay:
 2.8 days for TKA (national average is 3.9 days)
 2.7 days for THA (national average is 5.0 days)
– One MD able to perform eight joint replacements
before 2:00 p.m.
High Quality, Low Cost Care…
IHI’s New Project…
“How Do They Do That?”
– Identify High-Performing “Hospital Referral
Regions”
– Study the Dynamics of Their Health Economies
Variations in Practice and Spending
The Dartmouth Atlas and NIA Program Project Grants
Primary Funders:
Robert Wood Johnson Foundation
National Institute of Aging
Investigators
Dartmouth
Denise Anthony, PhD
Julie Bynum, MD, MPH
Elliott Fisher, MD, MPH
David Goodman, MD, MPH
Brenda Sirovich, MD,
Jonathon Skinner, PhD
John Wennberg, MD, MPH
Harvard
Kate Baicker, PhD
Michael Barry, MD
Amitabh Chandra, PhD
University of Massachusetts
Jack Fowler, PhD
Patricia Gallagher, PhD
University of Pittsburgh
Amber Barnato, MD
University of Toronto
Therese Stukel, PhD
Maine Medical Center
Lee Lucas, PhD
David Wennberg, MD,
American Board of Internal Medicine
Eric Holmboe, MD
Rebecca Lipner, MD
43
Variation in Resource Use Is
Enormous
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)
Highest Cost Regions Have:
•Worse Quality
•Same Access
•Lower Patient Satisfaction
•Lower Physician Satisfaction
•More Rapid Growth in Costs
44
We Have More to Learn
US High Performing Regions – 74 Out of 306
$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
The Triple Aim
Population
Health
Experience
of Care
Per Capita
Cost
North American Triple Aim
Prototyping Sites
• Health Plans
Blue Cross Blue Shield of Michigan (MI)
CareOregon (OR)
Eastern Carolina Community Plan (NC)
Essence Healthcare (MO)
UPMC Health Plan (PA)
Independent Health (NY)
• Integrated Delivery Systems (w/ Health Plans)
HealthPartners (MN)
Kaiser Permanente, Colorado Region (CO)
Kaiser Permanente, Mid-Atlantic Region (MD)
Martin’s Point Health Care (ME)
Presbyterian Healthcare (NM)
Southcentral Foundation and Alaska Native Medical Center
(AK)
Vanguard Health System
Veterans Health System:
 VISN 10—Cincinnati VAMC (OH)
 VISN 20—Portland VAMC (OR)
 VISN 23—Nebraska, Western Iowa VAMC (NE)
Wellstar Health System
• Social Services
Common Ground (NY)
Health Improvement Partnership of Santa Cruz
County (CA)
• Public Health Department
Washington DC Department of Health (DC)
• Integrated Delivery Systems (w/o Health Plans)
Allegiance Health (MI)
Bellin Health (WI)
Bon Secours - St. Francis Health System (SC)
Cape Fear Valley (NC)
Cascade Healthcare Community, Inc. (OR)
Cincinnati Children’s Hospital Medical Center (OH)
Erlanger Health System (TN)
Fort Healthcare (WI)
Genesys Health (MI) (Ascension)
• State Initiative
Vermont Blueprint for Health (VT)
• Safety Net
Colorado Access (CO)
Contra Costa Health Services (CA)
Nassau Health Care Corporation (NY)
North Colorado Health Alliance (CO)
Primary Care Coalition Montgomery County (MD)
Queens Health Network (NY)
• Employers/Businesses
QuadGraphics/QuadMed (WI)
• Canadian
Central East Local Health Integration Network
British Columbia Team
Saskatchewan Ministry of Health
Last Updated 9/21/09
International Triple Aim
Prototyping Sites
•
Jonkoping (Sweden)
•
NHS Blackburn With Darwen PCT (NW
England)
•
•
NHS Salford PCT (NW England)
•
NHS Somerset PCT (SW England)
NHS Bolton PCT (NW England)
•
NHS Swindon PCT (SW England)
•
NHS Bournemouth and Poole (SW England)
•
NHS Tayside (Scotland)
•
NHS East Lancashire Teaching PCT (NW
England)
•
NHS Torbay Care Trust (SW England)
•
NHS Blackpool PCT (NW England)
NHS Eastern and Coastal Kent PCT (South
East Coast England)
•
NHS Bury PCT (NW England)
•
NHS Central Lancashire PCT (NW England)
•
NHS Forth Valley (Scotland)
•
NHS Sefton PCT (NW England)
•
NHS Heywood, Middleton and Rochdale PCT
(NW England)
•
NHS Warrington PCT (NW England)
•
NHS North Lancashire Teaching PCT (NW
England)
•
NHS Western Cheshire PCT (NW England)
•
NHS Wirral PCT (NW England)
•
NHS Medway (South East Coast England)
•
•
NHS Oldham PCT (NW England)
State of South Australia, Ministry of Health
(Australia)
•
Western Health and Social Care Trust
(Northern Ireland)
•
Last Updated 7/21/09
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)
So… Where Next for Wales?
• “Constancy of Purpose for Improvement”
So… Where Next for Wales?
• “Constancy of Purpose for Improvement”
• Linkage of Improvement of Care to
Sustainable Cost – A Focus on “Muda”
Waste through Various Eyes
Patient
• Unnecessary repetition (exams, histories, investigations)
• Longer stays
• Avoidable complications
• Higher health care costs; risk of being uninsured (in US)
Nurse
• Time away from the bedside
• Searching for equipment
• Documenting
• Chasing down consults, test results, etc.
Physician
or Surgeon
• Time and unpredictability
• Unable to start operations or procedures on time
• Operating/procedure list over-runs
CFO
• Reduced margins
• Continuous financial pressure and the need to make “cuts”
• Frustration that QI promises savings, but rarely delivers
Ideas for Seeing Waste
• Think in the categories
• Walk with the patient through a visit or
care process
• Ask a nurse manager or department head
where they see waste (usually because
they are picking up from another
department)
Ideas for Seeing Waste
• Give the staff cameras and ask them to
take pictures of hassles and waste
• Keep a “grrrrrrr list” on the wall to attract
ideas from staff and physician hassles
• Use “spaghetti diagrams” to teach a
process
Our Vision Is Strategic Waste Reduction
From . . .
To . . .
• Arbitrary, reactive
cutting
disconnected to
the process of care
delivery
• A systematic, targeted set of
interventions designed to
simultaneously
• Improve patient outcomes
• Control costs
• Increase caregiver satisfaction
• Better dialogue and mutual
appreciation between clinicians and
managers
• Ability to engage caregivers in
dialogue about the allocation of
savings, once realized
The NHS Institute…..
Is 4 years old
….. supports the NHS to transform healthcare for patients and
the public by rapidly developing and spreading new ways of
working, new technology and world class leadership.
…..Believes that success in improvement and innovation
requires attention to Leadership, Measurement, Tools and
Techniques and Relationships
NHS Indicators – Clinical
•
Reduced variation in length of stay ( bed days saved)
AHT
•
Day case rate for Audit Commission basket for 25 procedures
AHT
•
Reduction in wasted bed days as a result of admission prior
to operation (without clinical indication)
AHT
•
Admission rates for selected procedures where thresholds for
surgery vary
PCT
•
Reduction of avoidable emergency admissions against
19 recognised diagnoses
PCT
•
Referral rate standardised - first Outpatient appointment
PCT
•
Proportion of statin prescriptions that are low cost
PCT
NHS Better care, Better value
Indicators – New for 2008/9
• Outpatient DNA rate
AHT
• Outpatient new to follow-up ratio
AHT
• Readmission rates – emergency
AHT
• Readmission rates – elective
AHT
• Prescribing basket
PCT
Typical Results
Time on direct patient care from 25-30% to 45-50%
Impact on Patient experience; LoS; Hospital acquired infection;
Pressure area care; Meal wastage; Inventory use……
Impact on morale; on sickness absence……
Impact on “self efficacy”…. “No going back” “Not a project; a way of
life”
“Everyday feels like a Sunday”
Potential to enable the Service to release
efficiencies via NHS Institute programmes…
e.g. The Acute Trust prize
Potential Acute Trust Productivity Opportunity
5000
£4,560
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£105
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based on estimates
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Value
• NHS Institutecommissioned
report on impact in
South West SHA
• Productive
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programme
Potential to enable the Service to release
efficiencies via NHS Institute
programmes… e.g. The PCT prize
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based on estimates
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Value
• NHS Institutecommissioned
report on impact in
South West SHA
• Opportunity Locator
So… Where Next for Wales?
• “Constancy of Purpose for Improvement”
• Linkage of Improvement of Care to
Sustainable Cost – A Focus on “Muda”
• Broadening the Agenda – beyond Safety
to Embrace All Dimensions of “Goodness”
The IHI Improvement Map
• 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 15 September 2009.
So… Where Next for Wales?
• “Constancy of Purpose for Improvement”
• Linkage of Improvement of Care to
Sustainable Cost – A Focus on “Muda”
• Broadening the Agenda – beyond Safety
to Embrace All Dimensions of “Goodness”
• Lead the World in Community-Wide
Design and Improvement
So… Where Next for Wales?
• “Constancy of Purpose for Improvement”
• Linkage of Improvement of Care to
Sustainable Cost – A Focus on “Muda”
• Broadening the Agenda – beyond Safety
to Embrace All Dimensions of “Goodness”
• Lead the World in Community-Wide
Design and Improvement
• Push the Boundaries of “Patient and
Family Centered Care” (PFCC)
IHI Measure of Patient-Centeredness
“They give me exactly the help I
need and want exactly when I
need and want it.”
(John Wasson Modification…)
“They give me exactly the help I need and
want exactly when and how I need and
want it.”
My Proposed Working Definition
Patient-Centeredness:
“The experience (to the extent the informed,
individual patient desires it) of
transparency, individualization,
recognition, respect, dignity, and choice in
all matters, without exception, related to
one’s person, circumstances, and
relationships in health care.”
THANK YOU!!
What you are doing is important…
•For Wales
•For the World