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Helen Macfie, Pharm.D., FABCSenior VP, Performance Improvement & Strategy

Certified Lean Leader

For IHI Patient Safety ExecutiveDevelopment Course, September, 2012

This presenter has nothing to disclose.

“What Was I Thinking??!!”

Session Goals

• So now you are a Patient Safety executive / CMO / officer / manager…some ideas to:1. Get started – the 100 day plan2. Obtain buy-in3. Set priorities4. Organize and resource the work5. Communicate results6. Sustain the momentum, for the long-

haulPlus: Developing your “personal power” so people will follow your lead

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It really is a journey

• Start where you are• There’s no one “best way”• Take the ideas you like, store the rest• It takes years…

1. 100 Day Plan

• Diving off the platform with:– What you came here with (your

experience, organizational history)

– This course under your belt (great!)

– Your plan/priorities outlined (key)

– And your Senior Leader buy-in (or plan to get that if they aren’t here)

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Keys to a 100 Day Plan

• Meet (re-meet) with key influencers and interview them about what they care about (take your IHI PSE homework and expand)– Executives, directors/managers, physician leaders,

front-line staff– Share your starting thoughts/Plan from this week– Don’t forget to meet with your direct reports too– Why?

• Initiate relationships, establish your role• Expand your perspectives• Learn the history (we tried that, it worked, didn’t work)• Understand your own biases (and adjust)

Keys to a 100 Day Plan

• Review current metrics/data Harm

Look at the forest firstTrigger tool review

Mortality2x2 analysis (last 50 deaths)

How displayed, and is it compelling?

Validate or tweak plan your PSO/E Plan prn(as needed) for the input received

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Keys to a 100 Day Plan

• Schedule sessions with your senior leader/mentor to report out

• Tackle some low-hanging fruit– Easy/early win(s), with visible impact– Could be:

• Educational session to relevant audience• Solving some problem that’s been hanging out there

(WOW)• Providing data in a meaningful way• Creating or strengthening an oversight team• Or your good idea goes here…

2. Obtaining buy-in

• Create the compelling vision with the broader community– Gaining the attention of a

focused audience– Make it “uncomfortable”,

create stretch

• Linking to strategy

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Getting the team onto one page• Ideas

– Start with your 100-day plan interviews

– Present findings to leadership

– Convene a “touchstone event”

• Pull in a big name if you can get the $

– Linking to your strategic plan (or department plan)

Concept: Aiming High, Aiming Wide

Breadth of Aim

Aim

High

System Level

Low

Unit Level

Islands of Excellence

Just Good Enough

Transformation

Incremental Improvement

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3. Setting priorities

• Understanding what’s important– Preventable mortality and harm

• Not taking on world health all at once– Create focus on the “vital few”

• Establishing bold targets

Concept: The Art of Selecting Targets• You want to create stretch

– Getting to transformation vs. improvement– “Better than average” or truly benchmark?– Thoughts on “Perfect Care” at the patient level– Going for Zero harm (“Zero Zone”)

• Having said that, start where your team can support, and evolve

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4. Organize and resource the work• Understand and work with

what you have– Organizational structures– Evolving as makes sense– Finding champions

• Learning from others• Leveraging “Reliability

Theory”

Concept: Use of IHI Reliability Theory

Chaos<80%

Tier 180-94.9% (X/10)

Tier 295-98.9% (xx/100)

Tier 399-99.9% (xxx/1000)

Flip of a coin; no design has stuck

Prevent initial failure Identify & mitigate failures

Redesign

• Reminder systems–Common equipment, standard orders sheets– Personal check lists

• Working harder next time• Feedback of information on compliance• Awareness and training

• Decision aids and reminders built into the system• Desired action the default (based on evidence)• Redundancy• Scheduling-takes advantage of habits and patterns• Standardization of process

• Failure Mode redesign only if articulated goal not reached

–Tackle one failure mode at a time–Relationships are mutually supportive

• Default care

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Incorporation of Five “Kata” Coaching Questions

• Coaching Kata – behavior or pattern 1. What is the target condition?2. What is the actual condition now?3. What obstacles are preventing you from reaching

the target condition?• Which are you addressing now?• Who out there is doing it better?• What toolkits already exist?• What could work here?

Incorporation of Five “Kata” Coaching Questions

4. What is your next step?• What could work here?• Who will champion this?• Who should be on the team to work out the details?• What tests of change can we do where, in order to test

our theories next Tuesday?• How to launch, educate, monitor and provide feedback?

5. When can we go and see what we have learned from taking that step?

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5. Communicate results

• Designing – What to share with Boards– How to engage your audiences

Concept: Better OutcomesAssociated with Hospitals where . . .

• The board spends more than 25% of its time on quality issues– The board receives a formal quality performance

measurement report– There is a high level of interaction between the

board and the medical staff on quality strategy– Hospital governing boards that have a single

committee that focuses exclusively or primarily on quality were found to be more likely to adopt various oversight practices and to have better clinical outcomes

Vaughn T, Koepke M, Kroch et. al. 2006Jiang, Lockee, Bass, Fraser. 2008

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Considerations

• Thoughts on what to share– Create focus (link to goals)– Show both successes and opportunities for

improvement– Rates OK but share the #s– The power of stories– Education on what this means– Pros/cons of different types of display (World Café

topic)

Concept: Bringing Patients and Families in to the room

• Storytelling• Imagine if it

was your mother, brother, grandfather, friend…

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Concept: PI Dashboard Development• What Boards and leadership

should do:– Understand and regularly oversee a

few system-level quality measures– Set specific “how good, by when”

aims for improvement of these system-level measures

• Where are we trying to get to• How will we know we got there

• Idea – Development of our “PI Radar” to:– Measure progress– Facilitate storytelling– Recognize success and opportunities

for further improvement

6. Building Momentum for the Long Haul• Back to that journey…• Adding in focus on

cultural evolution and tools

• Keep it consistent, and keep it fresh

• Growing your personal power inventory

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Concept: Culture & Tools

• Every year, reevaluate Bold Goals, plus work to round out supporting activities, examples:– Share sentinel event experience, gap closure– Re-focus on Just Culture (use of AHRQ survey)– Crisis management toolkit– Leveraging the EMR – hardwiring in Best Practices– Build of on-line dash-boarding

• Growing expertise in Lean, and the linkage to quality and safety, Visibility Boards

• Built in incentives for executives• The power of “touchstone events”, revisited

Concept: Leveraging “Value Based Purchasing”

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A few words on Personal Power• As a patient safety

executive, officer, manager – get an honest inventory your strengths, and opportunities

• Seek out resources, learning where you have opportunities

Leadership Competencies1. Team Leadership2. Communication3. Integrity and trust4. Ethics and values5. Motivating others6. Problem solving7. Managing vision and purpose

8. Priority setting9. Composure10. Listening11. Negotiating12. Conflict management13. Decision quality14. Building effective teams

Thank you!

• Questions?

• Contact Information:

• Helen Macfie, Pharm.D., F.A.B.C.– Senior VP, Performance Improvement– Hmacfie@memorialcare.org– 714-580-9009

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Appendix

Examples, Ideas, Tips and Tools

– Get started – the 100 day plan– Obtain buy-in– Set priorities– Organize and resource the work– Communicate results– Sustain the momentum, for the long-haul

Ex 1a: Measurement and display opportunities

Assessment• “Blocks of data”, not trended

– Low thresholds– Individual measures only

• No mortality measures• No harm measures

– Did monitor National Patient Safety Goals

• Internal safety culture survey– Non-benchmarked

• No patient survey measures

Data reflects patients eligible for the measure.

Indicator Goal

HF 1: Discharge Instructions

88% 91% 60% 78% 83% 100%

N/D 115 131 137 150 36 60 105 135 393 476

HF 2: LVF Assessment

92% 90% 92% 94% 92% 100%

N/D 140 152 173 192 72 78 152 161 537 583

HF 3: ACEI/ARB for LVSD

92% 84% 77% 82% 85% 100%

N/D 67 73 63 75 23 30 42 51 195 229

HF 4: Adult Smoking Cessation Advice

100% 97% 100% 88% 96% 100%

N/D 22 22 28 29 6 6 15 17 71 74

Source: MEDai Core Measures

*= downward trend = with color change = upward trend; = with color change

Numerator Denominator

This is the format for the above report.

Finding *Trend¹ SMMC and San Clemente data combined

Heart Failure Core Measures Performance Report

2nd Quarter 20054/1/05 - 6/30/05

= > 30% from Goal

MHSSMMC¹

Minimum sample is 225 patients per quarter or 100% of population

= > 10% and ≤ 30% of Goal = Within 10% of Goal

AMMC LBMMC OCMMC

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Ex 1b: Learning from a 2x2 analysis

• Findings/OFIs– Rapid response gaps– Coordination/goals not clear– Cardiovascular mortality (also in

our HSMR data – hospital standardized mortality rate)

IHI IMPACT “MOVING THE DOT” MORTALITY REVIEW TOOL

MR #: M M Admit Date:

Reviewer Init: Admit Unit: Attending:

Age: Sex: M F Note: do not look at the discharge diagnosis until after assess next 3 elements:

Admit Diagnosis:

Admit to Critical Care Unit?: Y N Admit for “Comfort Care”* with a terminal disease? Y N 2 x 2 Box:

Dischrg Diagnosis:

Principal ICD-9: Did the admitting and discharge diagnosis match? Y N

Comments:

* “Comfort Care”: as denoted in physician and/or nursing notes, not just DNR

BOX 4 Analysis (admitted to Non-CC Unit, not admitted for comfort care)

If admitting diagnosis differed from the discharge diagnosis, was there evidence of planning failures in first 48 hours of hospitalization that may have contributed to death?

Y N Maybe

Comments:

Is there evidence of a lack of responsiveness to nursing concerns by physicians caring for the patient?

Y N Maybe

Comments:

Did this lack of responsiveness play a factor in the death?

Y N Maybe

Comments:

Is there a transfer to the ICU prior to death? Y N

Comments:

Was there a Rapid Response Team call prior to death? What was the outcome?

Y N

Comments:

Is there a change to “no code” or comfort care prior to death?

Y N Day #:

Comments:

Is there evidence of an adverse event that occurred in the proximity of the progression to death (use ICU Trigger Tool Definitions – attached)

Y N

Comments:

Is there evidence of miscommunication occurring between providers, especially if there are more than 5?

Y N

Comments:

Box 4 Comments (continue on back for more space)

Created 03/06 hm [MemorialCare Mortality Dot Review Tool

The “2 x 2” Table

Ex 1c: Early Win –Find & Take It!

• Door to PCI– Baseline: 40%

within 120 minutes– Pulled together ED

and Cardiac for interdisciplinary effort

– Shared variation, tests of change

– Created competitive spirit

• Keys (for us)– Wasted minutes– Triage, atypical– ED decision power

• Outcomes, better!

0%

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AMI Core MeasuresAMI 8a: PCI within 90 minutes

MHS CMS Top 10%

AMI Core MeasuresAMI 9: Inpatient Mortality

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MHS CMS Top 10% Linear (MHS)

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Ex 2a: Leadership Summit

• Annual Summit – Feb, 2006 devoted to Quality & Safety

• Wide attendance (n=350)– Board members for system

and local entities– Hospital leaders– Physician leaders– Key managers

• Focus areas– Yes, we do cause harm, in #s– Leadership’s role is improving

quality and safety– Identifying key practices and

actions to accelerate the quality agenda

Ex 2b: Strategic Linkage

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Ex 3a: Strategic Quality PrioritiesReaffirm the Work Each Year

Big Dots 2006-13

Key Drivers Measures

Reduce Mortality

Reduce Needless Harm

Improve Patient & Family Experience

Early Response Clinical Reliability Sepsis Care

Endorsement and Loyalty

HCAHPS

Codes Outside ICU Perfect Care Sepsis Mortality

Reduced Infections Reduced

Complications

Central Line, VAP, CAUTI, SSI Hand Hygiene Stage 2-4 HAPU Patient Falls, all

Central Line, VAP, CAUTI, SSI Hand Hygiene Stage 2-4 HAPU Patient Falls, all VTE/DVT assessment &

prevention Medication reconciliation Breast cancer screening

Ex 3b-1: Evolving Our Bold Goals every Year2006-7: • Reduce mortality by 15%• Reduce code emergencies outside of the ICU

by 50%• Achieve “perfect care” of 95% for Core

Measures• Reduce hospital acquired infections (HAI) by

50%

Based on experience, team selected stretch for 2007-8:

• Further reduce mortality by 5% (net 20%)• Further reduce HAIs by 25% (net 75%)• Add: Reduce HA pressure ulcers by 50%

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Ex 3b-2: Evolving Our Bold Goals every Year

Review and stretch, every year2009-10:• Add: Achieve 100% hand hygiene compliance• Add: Reduce patient falls by 50%

2010-11:• Further reduce HAIs to Zero Zone • Add: Reduce sepsis mortality by 25%

2012-13:• Further reduce falls by 25% then to Zero Zone• Further reduce HAPUs to “Zero Zone”• Further reduce sepsis mortality by 5% (net 30%)• Further reduce HSMR to by 30%• Add: Achieve 95% Perfect Care: Medication

Reconciliation, VTE assessment + prophylaxis• Add: Achieve 90% breast cancer screening

Ex 4a: Physician Society structure, how to leverage?• A professional association of

physicians who are committed to participating in the development and utilization of evidence-based/best practice medicine.

• Responsibilities– Create the expectations for

clinical performance across the enterprise

– Lead development of best practices guidelines – with other disciplines

– Implementation of best practice guidelines

– Leadership of physician informatics and outcome related initiatives

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1996 1997 1998 1999 2000 2001 2002 20032004 2005 2006 2007 2008 2009 2010 2011

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Ex 4b: Mapping out your network

<< Shared services across our system >>

Ex 4b-1: Hand HygieneCross-VAT & BPT Collaborative

• Bold Goal – 100% effective hand hygiene

• New Campaign– Adapted from Novant

model, IHI– Standardized definition &

P&P– Marketing design,

reminders– Education for ALL– Retrained champions on

audit techniques, how to provide on-the-spot reinforcement

– Mirror clings everywhere

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Ex 4b-2: HAI Best PracticeTeam• Bold Goal – Get to ZERO

– Central Lines and VAPs– IHI 100K and 5M toolkits– Bundles, tape, checklists,

defaults– Multi-disciplinary rounds– Evidence-based review,

oral care– Build key elements in to our

EMR– Added CA-UTI– IHI Expeditions

Ex 4b-3: System-wide focus pays off

Campaign initiated

67-93% drop in serious hospital acquired infections.

187 patients’ Lives Touched for all infection types. And

more to do.

Hand Hygiene compliance

Central line infections

Ventilator associated infections

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Ex 4b-4: Building will, ideas and execution to take it even further

• This year leadership added reduction of CAUTI (catheter associated urinary tract infections) to our Bold Goals

• Staff nurse team came up with “NOCAUTI” campaign

• Tested and refined– One unit -> – To all hospital units

(critical care, med surg) ->

– To all medical centersInsertion:No germs (aseptic insertion, hand hygiene)Only when medically necessary (per criteria, documented, DC’d in ED/PACU unless order to continue)Maintenance:Clean (hand hygiene before and after care)Attach (catheter secured)Urine management (specimens from sample port only, placement of drainage bag below bladder, no kinks, emptied regularly, spigot kept clear of floor or graduated cylinder)Tidy (pericare wipes documented, absorbent pads, weighed for I&O)If no longer needed, removed (daily review)

All CAUTIs

Ex 5a: Evolving Capacity to Lead• Boards – we took stock of oversight capacity

in 2006

– Our Boards needed MUCH more education• Leadership Summit – identified gaps• Board study sessions, just in time• Patient stories and experiences• Glossaries and lay language• Sending to conferences (IHI’s Boards on Board)

– Board time on quality was low though increasing• Placing first on agenda

– System-wide sharing and oversight had started but opportunity to increase transparency/sharing

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Ex 5b: PI Radar DashboardShows where we started, have been, are now

Stretch targets

Scalable

Balanced

Performance over time

Inservice: Move out, to/beyond the green line

Ex 5c-1: The Rest of the StoryMortality & Rapid Response

World Café Recs

Next steps (who/ when/ status)

Finish rollout of order sets

• Order set designed – 6-24 hr released Mar’11; 0-6 hour ED StatPathreordered to make more user-friendly

External best practices

• Complete IHI expedition as well as participate in local SCPSC Collab.

• MEWS

Drilldown on Codes

• Reviewed at each campus, no barriers noted, continue to reinforce

Initiate reporting

• Develop reporting tool by physician for sepsis diagnosis and use of order sets –in progress for 3CQ’12

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Ex 5c-2: Lives Touched

Bold Goal MHS LBMMC MCH OCMMC SMMC

MortalityHSMR (ratio) – Medicare onlySepsis Mortality – full population

11867

185

597

66

n/a 160

16

4360

103

Perfect Care 95%Acute MI, HF, PN, Full SCIP pop 4,543 2,360

(Asthma)142 1178 863

Codes Outside ICU# RRT Calls last 12mo 1,316 826 n/a 273 217

Patient SafetyFalls to Floor Med/Surg, HAPU 185 48 n/a 63 74

Infection ReductionVAP, Central Lines, Cath-UTIs 177 40 93 9 35

Total Annualized Lives Touched based on 2011 volumes (these indicators) 6,406 3,440 235 1,539 1,292

Ex 5c-3: Lives TouchedCumulative

Based on Bold Goals each year compared to Baseline

MHS LBMMC MCH OCMMC SMMC

2007 2,805 1,635\

(n/a) 545 625

2008 5,765 2,812 252 1,419 1,282

2009 6,165 3,179 243 1,282 1,461

2010 6,084 3,129 347 1,292 1,316

2011 6,406 3,440 235 1,539 1,292

TOTAL 27,225 14,195 1,077 6,077 5,976

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Ex 5c-4: Another Number: > XXXX

PerfectCare 95%

XXX

PreventableInfections 0%(VAP/CL/UTI)

XX

PreventableHAPU 0%

(Stage III-IV)

XX

Patients WhoFall to the

Floor (10th goal)

XXX

Other 1301Reportable

Events

X

Mortality

XX

Ex 6a-1: Going to “Gemba”World Café planning exercise

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World Café Recs

Next steps (who/ when/ status)

Implemen-tation of Hourly Rounds, Skin Bundles

•Implemented, tracking compliance

Wound VAT to evaluate further best practices

•Referred to Wound VAT 1CQ – bed algorithm implemented, skin bundles in use, working on product algorithm

Wound VAT to create process for SNF/LTAC admit review

•Referred to Wound VAT 1Q –WOC nurses designed, partnering with nursing homes in community

Media manager implemen-tation

•Implementation planning and testing – task force mapped workflows, pilot conducted June, key issues identified to address

Ex 6a-2: Perfect Care – HAPUWorld Café Gap Loop Closure

Ex 6b: The SuperMECAnother “Touchstone”

• Convened Summer’11– Brought in two outside speakers– Talked about healthcare reform, Value-

Based Purchasing, physiciancompare• Key recommendations

– Leverage our Boards and MECs relationships to help us raise the bar and mandate best practices

• DVT/VTE assessment and prophylaxis• Medication reconciliation (Lean event)• Sepsis order set utilization

– Un-blind physician data for these 3 and other relevant Bold Goals

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Wrap-up: Safety Roadmap Since 2006

Assessment, Run Charts

Gap Analysis

Board Retreats

Perfect Care, Reliability Theory

Best Practice Collaboratives

Evolved “Quality Close”

IHI Impact (and now Passport)

Set Strategic “Bold Goals”

Board Agenda & Time

Evolved PI Dashboard

Ever Increasing Transparency

Aligning IncentivesLean (and PDSA)

Wrap-up: Helen’s “Top 10” Take-Away Ideas• These ideas worked for us, what will work for you?

1. Create and map “Bold Goal’ level quality aims right into your strategic plan. Select from Big Dots and Key Drivers.

2. Create time to discuss quality at all Board, senior leader, management and staff meetings.

3. Utilize patient stories, and involve patients and family members on committees

4. Involve physicians in a meaningful role to oversee, participate and champion the quality strategy.

5. “Plot your dots” (data over time), and include the raw # of patients harmed (not only the rate of harm). Raw #s are much more personal

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Wrap-up: Helen’s “Top 10” Take-Away Ideas• These ideas worked for us, what will work for you?

6. Harness the promise of Lean Thinking – focusing on bedside caregiver redesign to maximize “value-added” (vs. adding more steps/complexity)

7. If you have an EMR (and everyone will at some point), hardwire in best practices to make it easier for clinicians to do the right thing

8. Create a quality dashboard system that moves beyond tables or graphs, to a report that facilitates telling “the rest of the story”

9. Realize it takes years. But/and a plan or roadmap with strategic linkages will guide the journey and help tackle challenges in an order that makes sense to the culture of the organization

10.And finally, maximize your personal power