Moving Up Healthcare’s Second Curve:Strategies for Change

IE 6

11/6/201211/6/2012

1 t1st

2nd

2

3

2nd Curve: an IHI View

4

High Reliability in Medicine:Where Do You Need to Be?

Future Performance (Second Curve/

6+ Si )First Curve/

4 sigma

6+ Sigma)

4 sigma

(Craft-Age

(Craft+Information-Age Culture )

man

ce

(Bifurcation curve: 2000s)

(Craft-Age Culture)

Perf

orm

Time

Flexner 1910P

5-

Columns 2 & 3 = 2nd CurveColumns 2+3 = 2nd CurveRegulation Hammurabi

Medical Science

Hippocrates Management

Science

Legal system

State Boards

Nightingale, 4 doctors

Flexner Codman

Industrial Revolution

Taylor: “Scientific

JCAHO

“Inspection”

Flexner, Codman, ACS/Hospital

Standardization

M&M conferences

Taylor: Scientific Management”

Shewhart Inspection

Fed/State regs

M&M conferences

Donabedian,structure process, outcome

Deming, Juran,

Total Quality

ORYX, EMTALA,

HIPAA, Etc.

Outcomes, Disease

management

Complexity theory

Lean, Action Learning, Appreciative

6

JC, CMS “core

measures,” HCAHPS

Evidence based

care, Hospitalists

Learning, Appreciative Inquiry, Adaptive Design, High Reliability, Resilience

2 Historical Curves of Health Care Innovation(derived from Kuhn, Toffler, Morrison, Merry)

Future Performance (Second Curve/

6+ Si )First Curve/

4 sigma

6+ Sigma)

4 sigma

(Create and

(Transfer/Sustain Momentum)

man

ce

Human Factors 2000

Resilience,2010

(Bifurcation curve: 2012)

(Create and Build

Momentum)

Perf

orm

TQM, 1990

Factors, 2000

Time

Circa 1910P

7-

High Reliability and The Performance Curve

Safety Culture  Safety  Operating  Sigma Level Operating Level Performance 

LevelPerformance Level

Margin

Need A

Chaotic Below Average 0 None or in d fi itAwareness deficit

Reactive Normal Average 2 2%

Implementing Reliable Good P f

4 5%Performer

Proactive Highly Reliable High Performer 6 10%

Generative Ultrasafe Standard‐ 7‐9 20%Setter

The Healthcare Reform Paradigm Shift:another View

(From David Bates, MD)

Current Organization Integrated Care• Incented by volume• Focus on acute illness, high margin services• Focus on individual patient• Fill beds

P h i k

• Incented by value• Focus on prevention, care coordination• Focus on population• Prevent unnecessary admissions, readmissions

P id h i k• Payer has more risk • Provider has more risk

>>> HIT will be a key tool!

The Three Bucket Model

Bucket 1: Optimizing the First Curve

Bucket 2: Preparing to Move Up the Second Curve

Bucket 3: Moving Up the Second Curve and Distinguishing Yourself in the New Landscape of Healthcare

• Lean St d

• Co‐managementDi l i th t il

• Tri‐management3 l d l• Studer

• Emphasis on accountability

• EMR

• Dissolving the two siloes• Service Line 

Organization• Collaborative Rounding/ 

• 3 column model >>> new management science

• Strategy Learning • IHI• Root cause analysis/ gap 

analysis• PDSA

g/G.L.I.T.C.H. harvesting

• Safety Culture/ Safety Management System

• Relational law

gy gSystem

• Resilient System Design• Systemic Law• Systemic thinking• PDSA • Relational law

• Adaptive Design• Whole‐system Lean (Va. 

Mason, Thedacare)

• Systemic thinking• Cross‐ silo information 

management: beyond silos; manage better the information we have

Leading for Change

Bucket 1: Optimizing the First Curve

Bucket 2: Preparing to Move Up the Second Curve

Bucket 3: Moving Up the Second Curve and Distinguishing Yourself in g gthe New Landscape of Healthcare

• Focus on dataE h i bl l i

• Widen the lens: focus on both lit ti d tit ti

• Use information with it ti l ti• Emphasize problem‐solving

• Root cause analysis• More effective execution of 

established methods (i.e. for preventing central line 

qualitative and quantitative information 

• Precede problem‐solving withproblem‐finding

• Reach out: more information, 

situational awareness, creating contextual knowledge

• Combine problem‐solving and problem‐finding with problem‐framing and situational 

infections) wider network, more resilient (cf. Kim Cameron, FAA)

• Add appreciative inquiry• A shift of assumptions on the 

design criteria for care systems

deployment• Add positive deviation, success 

story analysis, and action learning/ ongoing experimentationdesign criteria for care systems 

and what performance levels are possible and necessary (e.g. from % to Sigma thinking)

experimentation

Buckets 1 & 2: Central Line InfectionsBuckets 1 & 2: Central Line Infections

• Bucket 1: Moving from the assumption of “aBucket 1: Moving from the assumption of a minimal number of inevitable infections that are inherent in the procedure” by just applyingare inherent in the procedure by just applying known preventive measures more rigorously

• Bucket 2: Achieving 0 infections and in so• Bucket 2: Achieving 0 infections, and in so doing, changing our assumptions about achievable performanceachievable performance

1st Curve Breast Diagnosisg

Initial Concern

Surgery Consult

OR/O BiOR/OpenBiopsy

Biopsy ReadBiopsy Read

Patient Learns(Cycle time of process built around practi-tioners: 1-8 weeks)

13

Patient Learnstioners: 1 8 weeks)

Bucket 3: 2nd Curve Breast Diagnosis, Park-Ni ll t H lth S t 1995 P tNicollet Health System, 1995 - Present

Screening Xray

Immediate Reading

S i BiStereotactic Biopsy

Biopsy Read(Cycle time f Biopsy Read

Patient Learns

of process built around patients: 2

14

Patient Learnshourspossible.)

Hypothesis: We cannot problem-solve our way to 2nd Curve High Reliabilityour way to 2 Curve High Reliability

Problem Solving “Appreciative Inquiry”

Problem identified

Appreciating/valuing best of “What is”

Analysis of causes

Possible solutions

Envisioning “What might be”

Dialoguing “What should be”Possible solutions

Action planning

Dialoguing What should be

Innovating “What will be”

Assumption: Success = problems solved

Assumption: Success = a possibility envisioned/created

f

15

‐adapted from Bernard Mohr

Creating 2nd Curve Culturesg

“Changing how 2nd Curve Vision

g gwork is done changes the

Change Processes

Ch S

gculture.”

- Jeff Goldsmith, PhD

Change Structures

Change WorkChange Work

2nd Curve Culture16

2 Curve Culture

The Policy Environment: Affordable Care ActAffordable Care Act

• New insurance rules guaranteeing coverage• High-risk pool for people with pre-existing conditionsHigh risk pool for people with pre existing conditions• Protection for children with pre-existing conditions• Coverage for young adults, to age 26

S ll b i t dit• Small business tax credits• Preventive care, free for proven services• Early retirees temporary reinsurance• “Doughnut hole” rebates for Medicare• Annual review of premium increases• Access to care: $ Billions for Community Health CentersAccess to care: $ Billions for Community Health Centers

and the National Health Service Corps for low-income and uninsured

• New incentives for providers (ACOs, CMS rewards and

17

New incentives for providers (ACOs, CMS rewards and penalties, shared gain provisions)

“Physician leadership is essentialPhysician leadership is essential. Improving the value of health care is something only medical teams can dosomething only medical teams can do. . . Physicians can lead this change and return the practice of medicine to its appropriatethe practice of medicine to its appropriate focus: enabling health and effective care.”

18

- Michael Porter, PhD, MBA

Bucket 3: 2nd Curve Structure InnovationInnovation

Community Memorial HospitalCommunity Memorial HospitalMenomonee Falls, WI

19

A 1917 Design, as of 2012

Board of TrusteesChi f E tiM di l St ff E ti

Chief Executive

OfficerMedical Staff Executive

Committee

• Credentialing

Medical Staff Functions(“Silo 1”)

• Nursing

Hospital Functions(“Silo 2”)

• Credentialing• Departmental (Peer)

Review• Surgical Case Review

• Nursing• Ancillary• Laboratory• RadiologyDepartmentsSpecialties

• Blood UR• Drug Usage Review• Pharmacy and

Therapeutics

• Physiotherapy• Risk Management• Finance, Planning• Regulatory Agencies

2012: The Structure Hierarchy, F t ti C i ti

20

Therapeutics• Medical Records

Regulatory Agencies• Etc.Fragmentation, Communication gaps,

Misunderstanding, Power Struggles, etc.

“Doctor, I’d like you to resign from thi di l t ff f f illthis medical staff for reasons of ill health. You make me sick.”

21

The Vision

1. Reduce physician time spent in wasteful Medical Staff activities.

2. Increase the influence of physicians in the development of service lines and the redesign of clinical g fmicrosystems.

3 Clinical microsytems that perform3. Clinical microsytems that perform more efficiently and effectively for both patients and caregivers

22

both patients and caregivers

Board of Trustees

The Starting Pointoa d o us ees

Quality Improvement Oversight

Medical Care

Medical Executive Committee

Senior Mgt. Team

Patient/Medical Staff Functions

Operational Management

Patient/ Community

Leadership Caregivers

23

COMMUNITY MEMORIAL HOSPITAL,

Hospital Board

Management and

Hospital

AdministrationMedical Executive Committee

Management and Coordination of Care

Participation Managementrativ

ecep

Leadership Patient/Community

Management

Design

Col

labo

rP

ract

i

Performance Improvement

24K:\S\wp\7350(953)\misc\janice8.ppt* Specialties provide care in all service lines

SuppliersPayors and Funders

An Emerging Model‐SCS Innovation Strategy 

Payors and FundersIncrease  Access to centers of excellence

Increase Access  to Outpatient CareLong  waits for Services in the community

Translate Data into practice

Lack of accountability in Hospital  Planning 

Lack of community servicesthe community

Taking a regionalperspective on research

Increase connections withPrimary care

•Improve CareIncrease in options for community re‐integration

Unique challenges for

Delivery 

Need for communitynavigation

Primary care

Expanding Caregiver

p•Reduce Cost•Create Jobs

Need to create systemsperspective on care

Unique challenges for specific populations of care System

Hospitals, Community services need to focus on recovery and  medical issues

Increase access to 

Expanding CaregiverPilots 

Expand wellness programs– e.g. Fit for Function

Need for strategicCollaborations/partnerships

p ,Providers, 

Carerehab for acute chronic conditions

Lack of awareness of Community programs

Collaborations/partnerships

Increase need for Peer support – survivor groups

Need to focus on transitions Need to collaborate withother strategies i e COPD

Care Networks

other strategies – i.e. COPD, Diabetes, cardiovascularImportance of timeliness

of treatmentIncrease partnerships with case management

Coordinated Pediatric Care

1 t1st

2nd

26

27

2nd Curve: an IHI View

28

High Reliability in Medicine:Where Do You Need to Be?

Future Performance (Second Curve/

6+ Si )First Curve/

4 sigma

6+ Sigma)

4 sigma

(Craft-Age

(Craft+Information-Age Culture )

man

ce

(Bifurcation curve: 2000s)

(Craft-Age Culture)

Perf

orm

Time

Flexner 1910P

29-

Columns 2 & 3 = 2nd CurveColumns 2+3 = 2nd CurveRegulation Hammurabi

Medical Science

Hippocrates Management

Science

Legal system

State Boards

Nightingale, 4 doctors

Flexner Codman

Industrial Revolution

Taylor: “Scientific

JCAHO

“Inspection”

Flexner, Codman, ACS/Hospital

Standardization

M&M conferences

Taylor: Scientific Management”

Shewhart Inspection

Fed/State regs

M&M conferences

Donabedian,structure process, outcome

Deming, Juran,

Total Quality

ORYX, EMTALA,

HIPAA, Etc.

Outcomes, Disease

management

Complexity theory

Lean, Action Learning, Appreciative

30

JC, CMS “core

measures,” HCAHPS

Evidence based

care, Hospitalists

Learning, Appreciative Inquiry, Adaptive Design, High Reliability, Resilience

2 Historical Curves of Health Care Innovation(derived from Kuhn, Toffler, Morrison, Merry)

Future Performance (Second Curve/

6+ Si )First Curve/

4 sigma

6+ Sigma)

4 sigma

(Create and

(Transfer/Sustain Momentum)

man

ce

Human Factors 2000

Resilience,2010

(Bifurcation curve: 2012)

(Create and Build

Momentum)

Perf

orm

TQM, 1990

Factors, 2000

Time

Circa 1910P

31-

Leading for Change

Bucket 1: Optimizing the First Curve

Bucket 2: Preparing to Move Up the Second Curve

Bucket 3: Moving Up the Second Curve and Distinguishing Yourself in g gthe New Landscape of Healthcare

• Focus on dataE h i bl l i

• Widen the lens: focus on both lit ti d tit ti

• Use information with it ti l ti• Emphasize problem‐solving

• Root cause analysis• More effective execution of 

established methods (i.e. for preventing central line 

qualitative and quantitative information 

• Precede problem‐solving withproblem‐finding

• Reach out: more information, 

situational awareness, creating contextual knowledge

• Combine problem‐solving and problem‐finding with problem‐framing and situational 

infections) wider network, more resilient (cf. Kim Cameron, FAA)

• Add appreciative inquiry• A shift of assumptions on the 

design criteria for care systems

deployment• Add positive deviation, success 

story analysis, and action learning/ ongoing experimentationdesign criteria for care systems 

and what performance levels are possible and necessary (e.g. from % to Sigma thinking)

experimentation

Buckets 1 & 2: Central Line InfectionsBuckets 1 & 2: Central Line Infections

• Bucket 1: Moving from the assumption of “aBucket 1: Moving from the assumption of a minimal number of inevitable infections that are inherent in the procedure” by just applyingare inherent in the procedure by just applying known preventive measures more rigorously

• Bucket 2: Achieving 0 infections and in so• Bucket 2: Achieving 0 infections, and in so doing, changing our assumptions about achievable performanceachievable performance

The Policy Environment: Affordable Care ActAffordable Care Act

• New insurance rules guaranteeing coverage• High-risk pool for people with pre-existing conditionsHigh risk pool for people with pre existing conditions• Protection for children with pre-existing conditions• Coverage for young adults, to age 26

S ll b i t dit• Small business tax credits• Preventive care, free for proven services• Early retirees temporary reinsurance• “Doughnut hole” rebates for Medicare• Annual review of premium increases• Access to care: $ Billions for Community Health CentersAccess to care: $ Billions for Community Health Centers

and the National Health Service Corps for low-income and uninsured

• New incentives for providers (ACOs, CMS rewards and

34

New incentives for providers (ACOs, CMS rewards and penalties, shared gain provisions)