INNOVATION:

Building the Culture &

Realizing the Benefits

Presented by:Rolando BarriosJulian MarsdenBarbara Trerise

National Healthcare Leadership ConferenceJune 6, 2011

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Purpose

• Understand the approach Providence Health Care is

taking to building a culture of innovation

• Hear about the experience and some lessons learned on

the bleeding edge of innovation

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Providence Health Care

• 6,000 staff

• 1,000 physicians

• 1,400 volunteers

• $709-million budget

• 8 sites + 7 community dialysis clinics

• 1,500 beds (acute, residential, rehab, assisted living and hospice)

• Academic Health Science Centre with PHC Research Institute

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A nation’s (organization’s) culture resides in the hearts and in the souls of its people.

Mahatma Gandhi

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Agenda

• Building an Culture of Innovation at Providence Health

Care

• Evidence to Excellence

• Immunodeficiency Clinic

• Lessons learned

• Questions

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Quality and Safety Enablers

• Strategic directions and annual plans;

• Accountability and Performance Improvement Framework;

• Support infrastructure

• Quality and Lean, Change Initiatives, Administrative Decision Support, Safety, Practice Consultants and Infection Prevention and control, expert skills, accessible data and data analysis

• Organizational structure;

• Program management, executive responsibilities, committees, engaged board

• Capacity building;

• Team and leadership development, standard project management methodologies, visible CEO leadership, stakeholder engagement

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“The organization demonstrates a strong commitment to quality

and safety and has developed this culture across the organization.

Providence Health Care is a model organization. It is evident…that

there is a culture of quality improvement. There is a systematic

process to understand, manage and communicate quality from a

system-wide perspective from the board level, to the leadership

team right to front line staff. The surveyors saw many examples of

quality improvements and innovation to improve work life and the

quality of patient care. Furthermore there is an awareness at all

levels of the tools that can be utilized to make improvements to

their areas.”

Accreditation Canada

November 2010

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2010 Self Assessment

• Positive reputation – awards, examples of innovation,

sought out by others, lots of firsts, pockets of excellence

and innovation

• Pace of improvement is too slow

• Uptake of new knowledge is spotty and spread is difficult

• Lack of reliability

• No real priorities

• Reputation exceeds our current performance

• Relying on structures, methods and skills designed for a

different time and strategy

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What is Innovation?

• No commonly agreed upon

definition

• A discovery and/or invention that:

• Is unique

• Has value, and is

• Worthy of spreading, exchanging with others, or commercialization

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Perceptions of Executive Teams –Weiss & Legrand

Innovative

Org

Non-

innovative

Org

Innovation is important to organization’s

future success

95% 79%

Executives believe innovation is crucial 86% 24%

Executive team is an excellent example

of teamwork

67% 12%

Executives understand the process of

innovation

68% 6%

Executives role-model innovation

practices

68% 2%

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Dimensions of a Culture of Innovation –What the Evidence Says….

• Performance orientation and everyone understands the

organizational direction

• Risk taking that adds value is expected and supported;

acceptance of failure

• Innovation is a priority and there is autonomy to try new things

• Executive team model the way and remove barriers

• Orientation to people and teams - enabled with trust, honesty,

transparency and diversity

• Balance innovative thinking with the discipline to implement

solutions

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Seven Dimensions of a Culture of Innovation - NHS

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THINK PHC

To transform the health of the populations we serve through innovative solutions and new knowledge

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Aims of ThinkPHC

• To develop a model which will accelerate the pace, impact and spread of

change in support of quality improvement, financial and other

performance targets;

• To improve the quality of clinical care through accelerating the adoption

of research findings and new knowledge by care providers;

• To increase leadership, team capacity and skill to effectively engage in,

and sustain innovation

• To further PHC’s contributions to the health system through leading

practice and knowledge translation

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Our approach …

• Executive consensus

• Board support

• Institute for Healthcare Improvement

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IHI Recommendations Action/Next Steps

Assure leadership clarity of

purpose

Vision statement

Innovation strategy; strategic

planning process

Select the vital few aims Quality and safety foci:

• Patient centeredness

• Harm

• Reliability

Measures, drivers, detailed plans; what and how do we let go

Assure academic integration into

work and focus on physician

engagement

Research leadership and

engagement; R&D team

Innovation strategy

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IHI Recommendations Action/Next Steps

Develop an innovation focus to

assure continuing projects and

plan for spread

R&D team

Spread plan

Align organization resources to

support the work

Leadership – VP, Corporate Director, ThinkPHC

Innovation Team - Change Initiatives, Accreditation, Administrative Decision Support, Quality; Practice

Improve organizational

practices to support and

assure a ‘Line of Site from

front line to executives and the

board

Effective Governance

Innovation strategy; assess risk; manage the whole as well as the parts; make the work visible through cascading strategies and metrics

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Innovation Strategy• Culture of Innovation - Vision

• PHC has a reputation for its dynamic culture of innovation leading to excellent health outcomes. It is widely known for a "performance orientation" with a focused, rapid-paced approach to inquiry, innovation and implementation that other organizations wish to emulate.

• Plan

• Culture

• Quality and safety

• Effective Governance

• Leadership

• Academic integration

• Organizational practices

• Metrics

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Acknowledgements

• Board of Directors

• Senior Leadership Team

• Innovation Team Directors

• Inspirational researchers and providers

Evidence 2 Excellence: BC Emergency Medicine Improvement Community

2011 National Healthcare Leadership Conference June 6th, 2011

Julian Marsden MD

A Collaborative Improvement Network:

To create a sustainable culture of improvement

A community of health care providers and administrators committed toexcellence in emergency health care for all British Columbians.

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The Journey of E2E

1. Why E2E?

2. What is E2E?

3. How does it work?

4. What have we done?

5. What next?

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Why was E2E created?

1. An opportunity to leverage all the good work that is already being done:

> Share and spread improvements across BC

> Accelerate improvements

2. Create new networks and partnerships to bridge:

> Rural-urban divide

> Interprofessional divide

What is E2E?

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Implement & Spread

Sustain & Monitor

Design & Develop

Improvement Life Cycle

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Implement & Spread

Sustain & Monitor

Design & Develop

Scope & Elements of E2E

Grassrootsdriven

Provincial Communit

y&

Network

Knowledge

Translation

Academic

Evaluation

Quality

Improvement

Adapt to local

context

Interprofession

al collaboration

MoHS Supported

(BC PSQC)

How does it work?

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www.evidence2excellence.ca

Community of Practice

Homepage

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The Collaborative Model

The Breakthrough Series: IHI’s Collaborative Model for Achieving

Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. (Available on www.IHI.org)

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Approval Process

• Topics chosen by the E2E community

• Involvement is voluntary

• Executive sponsorship required

> Responsibility of individual site or health authority

• All teams submit a monthly self assessment report of their progress against the collaborative action areas.

What have we done?

Our Successes

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Website Usage

• ~700 resources posted

• YouTube video has 350+ views to date worldwide

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0

500

1000

1500

2000

2500

3000

Apr-

10

May-1

0

Jun-1

0

Jul-

10

Aug-1

0

Sep-1

0

Oct-

10

Nov-1

0

Dec-1

0

Jan-1

1

Feb-1

1

Mar-

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Number of E2E Website Visits

Number of visits

Cumulative visits

2,570

109 100 26 11 5 3 3 2 2 10

500

1,000

1,500

2,000

2,500

3,000

Provincial Visits

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2009-10 Collaborative Overview

Jan 2011Virtual

January 16th

2010Vancouver

March 25th

20103 hoursVirtual

May 28th 2010Partial

Attendance +Virtual

Oct 16th 2010Partial

Attendance +Virtual

Oct 2009

Jan 2010May –Oct 2010

Oct – Dec 2010

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2008-2009 Collaboratives

• 36 teams from 26 sites>13 ED Sepsis Teams>23 ED Triage Teams

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2009-2010 Collaboratives

• 38 teams from 26 sites�20 ED Flow Teams�18 Sepsis Teams

• 200 + TEAM MEMBERS registered• All Health Authorities represented

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Province Wide Rounds

• E2E began hosting Provincial Wide Rounds in June 2010.

• WebEx presentations by key leaders in Sepsis research/care or improving ED Flow.

• Each talk attracted 100 participants.

Dr. Emanuel Rivers Dr. Derek AngusDr. Grant Innes

Mary Ackenhusen COO

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Data Collection

• All teams submit a monthly self assessment report of their progress against the collaborative action areas.

• ED Flow

> Data obtained from Health Authority Decision Support to assess teams progress against the ED Flow goals

• Sepsis

> Sepsis teams manually collect data on patients that meet the criteria for Systemic Inflammatory Response Syndrome (SIRS)

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Team Self Assessment (Sepsis)

Self Assessment Scale

1.0 Forming a team

1.5 Planning for project begun

2.0 Activities but no changes

2.5 Changes tested - no improvement

3.0 Modest improvement

3.5 Improvement

4.0 Significant improvement

4.5 Sustained improvement

5.0 Outstanding

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Team Self Assessment (ED Flow)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

% o

f te

am

s re

po

rtin

g

AV

E S

elf

Ass

ess

me

nt

SUMMARY ED Flow Self Assessment

Ave Self Assessment Score

% of Teams Reporting

Self Assessment Scale

1.0 Forming a team

1.5 Planning for project begun

2.0 Activities but no changes

2.5 Changes tested - no improvement

3.0 Modest improvement

3.5 Improvement

4.0 Significant improvement

4.5 Sustained improvement

5.0 Outstanding

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What did the Sepsis teams do?

• created sepsis posters

• developed sepsis screening tools

• created Pre-printed Order Sets

> nurse initiated

• improved communication strategies

• adopted a report card system to highlight issues

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And the ED Flow teams?

• process maps

• a triage surge plan - flexible triage staffing model

• match capacity to demand

> studied patient volumes

> at triage

> waiting for an ED bed

> waiting for admission/ discharge

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ED Flow continued

• monitored and controlled for incident report issues

• standardized equipment and supplies

• tested for bed control/access services

• trialed and created a Rapid Assessment Zone to allow for quick turn around of CTAS 3 patients

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

%

Patient # in chronological order

Percent within target for Site X

% patients getting

fluid in < 90 min

% patients getting

Abx in < 60 min

Improvement in Fluid

Time Trend line

Time Trend line

Improvement in Abx

Time Trend line

Example of Sepsis Results

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0

500

1000

1500

2000

2500

0.00

10.00

20.00

30.00

40.00

50.00

60.00

Nu

mb

er

CTA

S 3

Pati

en

ts

Min

ute

s

Time to Physician for CTAS 3 Median Value (min)

Number CTAS 3 Patients Time to Physician for CTAS 3 (min)

Improvement in

time to physician

for CTAS 3 (trend)

Example of ED Flow Results

The Challenges

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The Challenges

1. Collaborative experience variable

2. Finite resources & competing priorities

3. Data measurement & reporting

4. Clinician engagement

5. Funding stability

What next?

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Going Forward

1. Demonstrate value & results

2. Increase awareness of collaborative process

> Action orientated

3. Align with decision/policy makers/other grps

4. Broaden value

> Beyond the ED

5. Lengthen timeline

> Beyond “collaborative projects”

6. Academic evaluation

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In Summary, E2E is a model:

1. A tremendous opportunity to leverage all the good work that is already being done:

> Share, spread & accelerate improvements

2. Create new networks and partnerships to bridge:

> Rural-urban divide

> Interprofessional silos

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Acknowledgement

• Dr. Lawrence Cheng

• Dr. Mike Ertel

• Dr. Ran Goldman

• Ali Gregory

• Dr. Kendall Ho

• Dr. Kirk Hollohan

• Dr. Grant Innes

• Dr. Sandra Jarvis-Selinger

• Noreen Kamal

• Christina Krause

• Dr. Julian Marsden

• Anna Needs

• Dr. Helen Novak Lauscher

• Katie Procter

• Sherry Stackhouse

• Dr. Rob Stenstrom

• Dr. David Sweet

• Brent Woodley

• Lindsay Zibrik

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Acknowledgement

• All the teams and team members who committed their time and energy to this work

• BC Ministry of Health

• BC Patient Safety and Quality Council

• UBC eHealth Strategy Office

Thank you.

Innovation:Immunodeficiency ClinicProvidence Health Care

Rolando Barrios, MD, FRCPCOn Behalf of the Quality Improvement TeamHIV/AIDS Outpatient ProgramProvidence Health Care

BackgroundInnovation – RedesignWhat was our comparator?Results: How did we knew we changed?Impact on other Programs

Background

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HIV/AIDS

HIV – changing epidemic

Antiretroviral (ARV) Therapy

•Better, more tolerable, simpler combinations

•Decreases morbidity and mortality

•Increases survival and return to a productive life

HIV – Became chronic manageable disease

•Stigma, adherence, competence important differences

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However …. not every one benefiting from ART

Community Consultation:

Most of the admissions to hospital were preventable (e.g. PCP)

Significant number of “orphan” patients

Using ER for primary care

Complex co-morbidities (e.g. mental health, addictions, hepatitis)

Providence Health Care – Leading HIV/AIDS Program in the province

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Partners:

BC Centre for Excellence in HIV/AIDS

Providence Health Care

Innovation

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Redesign:

•Focus on patient centre care

•Accessible, flexible (low-threshold), quality

•Interdisciplinary approach

•Complex medical/psycho-social issue

•Proactive care

•Informed patient interacting with a prepared proactive team

•Clinical information systems

•Monitor individual and population outcomes

•Evaluation

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Adapted the Chronic Disease Model

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Quality Improvement Model

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Evaluation

What comparators were used when assessing Quality?

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What comparators were used when assessing Quality: Clinical Practice Guidelines

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Clinical Information Systems

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INDICATORS

Results

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Cumulative number of patients registered in IDC for HIV Primary Care

Data source: IDC Database

7474Source: IDC Database (Dec-2009)

INDICATORS: Screening Immunization

INDICATORS: Population CD4s & Plasma Viral Load

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Patient : Physician contact time

0

10

20

30

40

50

60

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Baseline Dec-04 Dec-05 Dec-06 Dec-07 Dec-08 Dec-09

# m

inu

tes

Data sources: IDC Database and Physician sessional utilization data

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Impact on ER and admissions to hospital

Linkage of IDC and New Emergency Room Database.

ED visits leading to hospitalization decreased from 64% to 27% (1)

(1) Barrios R, et al., XVI International AIDS Conference, Toronto 13-18

August 2006 Abstract Number: A-011-0103-03610.

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Impact on other programs

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Vancouver Native Health Clinic

David Tu, et al. 2010

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Central Interior Native Clinic

Balda P. et al. Unpublished 2011

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Provincial Structured Learning Collaborative: STOP HIV/AIDS

Based on IHI framework

Launched Jan 2011

Using same models of Care and Quality Improvement

20 Primary Care teams across the province are actively participating

The aims of the collaborative are to increase linkage and retention in HIV care.

Expected to be completed by January 2011

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Thank you!

Contact e-mail:

rbarrios@cfenet.ubc.ca

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Questions