Leading Together Maureen Bisognano President and CEO IHI UT System Clinical Safety and Effectiveness...

Leading Together

Maureen Bisognano

President and CEO

IHI

UT System Clinical Safety and Effectiveness Conference

October 27, 2011

Aims for Today

• Look out at the challenges we share in the coming year

• Look around for ideas and models

• Look in and celebrate the amazing work you are doing

Our Challenges

• Structural challenges in this time of reform

• Health needs and challenges in the populations we serve

• Managing the complexity in caring for patients

Making Sense of It All

Scores: Dimensions of a High Performance Health System

75

70

67

52

69

67

73

71

57

53

71

65

70

75

55

53

69

64

0 100

Healthy Lives

Quality

Access

Efficiency

Equity

OVERALL SCORE

2006 revised

2008 revised

2011

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 5

* Note: Includes indicator(s) not available in earlier years.

*

*

76

88 8981

88

99 97

109116

106

97

134

115 113

127120

55 57 60 61 61 64 66 67 74 76 77 78 79 80 8396

0

50

100

150 1997–98 2006–07

Deaths per 100,000 population*

* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.See Appendix B for list of all conditions considered amenable to health care in the analysis.Data: E. Nolte, RAND Europe, and M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files and CDC mortality data for U.S. (Nolte and McKee, 2011).

Mortality Amenable to Health Care

HEALTHY LIVES


7.2 7.0 6.9 6.8 7.0 6.8 6.8 6.9 6.7 6.8

10.311.1

10.2 9.9 9.9 9.610.1

10.810.0 9.9

5.3 5.1 5.0 4.9 4.8 4.7 4.7 5.0 5.0 5.0

0

4

8

12

1998

1999

2000

2001

2002

^20

03

2004

^20

0520

0620

07

U.S. average Bottom 10% states Top 10% states

National average and state distribution International comparison, 2007

2.02.5 2.6 2.7

3.14.0

5.1

6.8

Iceland

SwedenJapan

Finland

Norway

Denmark

Canada

United States

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

Infant Mortality Rate

Infant deaths per 1,000 live births

^ Denotes years in 2006 and 2008 National Scorecards.Data: National and state—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003–2008; Mathews and MacDorman, 2011); international comparison—OECD Health Data 2011 (database), Version 06/2011.

HEALTHY LIVES

7

87

59

49

9389

8374

66

98 97 96 9490

71

81

0

25

50

75

100

90th %ile 75th %ile Median 25th %ile 10th %ile

2004 2006 2009

Hospitals: Prevention of Surgical Complications


QUALITY: EFFECTIVE CARE

Percent of adult surgical patients who received appropriate care to prevent complications*

* See Appendix B for methods and description of clinical indicators.Data: IPRO analysis of data from CMS Hospital Compare.

Percent of hospitalized patients with new prescription who reported prior medications were reviewed at discharge

Medications Reviewed When Discharged from the Hospital, Among Sicker Adults, 2008

Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized or had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom; US=United States.Data: 2008 Commonwealth Fund International Health Policy Survey.

QUALITY: COORDINATED CARE


5457 59 59 59 60

67

77

0

25

50

75

100

NZ FRA CAN NETH UK AUS US GER

Potentially Preventable Adverse Events and Complications of Care in Hospitals

Adjusted rate per 1,000 discharges*

2002 2003 2004 2005 2006 2007

Failure to rescue 141.7 135.0 128.9 120.4 114.0 105.7

Decubitus ulcers 22.1 23.4 24.7 24.1 24.6 25.1

Selected infections because of medical care

2.3 2.3 2.3 2.3 2.2 2.0

Postoperative pulmonary embolus or deep vein thrombosis

9.6 10.3 10.7 10.7 11.2 11.5

Postoperative sepsis 11.1 11.7 13.2 13.7 15.1 15.4

* Rates are adjusted by age, gender, age-gender interactions, comorbidities, and Diagnosis Related Group (DRG) clusters. Data: Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (retrieved from HCUPNet at http://hcupnet.ahrq.gov).

10

QUALITY: SAFE CARE


http://hcupnet.ahrq.gov/

Difficulty Getting Care After Hours Without Going to the Emergency Room, Among Sicker Adults, 2008

2734

3945

56 58 59 59

0

25

50

75

100

NETH GER NZ UK CAN US AUS FRA

QUALITY: PATIENT-CENTERED, TIMELY CARE

Percent of adults who sought care reported “very” or “somewhat” difficult to get care on nights, weekends, or holidays without going to the emergency room

Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized or had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom; US=United States.Data: 2008 Commonwealth Fund International Health Policy Survey.


Our Challenges




THE COMMONWEALTH

FUND

Figure 1. Growth in the Number of People Age 65 and Older

96% 96% 95% 95% 93% 92%91%

90%89% 87%

88%87% 84% 80%

79%80%

4%4%

5%5%

7%8%

9%

10%11%

13%

12%13%

17%20%

21%

20%

0

50

100

150

200

250

300

350

400

450

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Num

ber

(in m

illio

ns) 65+

Under 65

Sources: 1900 to 2000 data are from Hobbs, F., & Stoops, N. (2002). Demographic Trends in the 20th Century (Census 2000 Special Reports, CENSR-4). Washington, DC: U.S. Census Bureau. Available at http://www.census.gov/prod/2002pubs/censr-4.pdf. 2010 to 2050 data are from Population Projections Program (2000). Projections of the Resident Population by Age, Sex, Race, and Hispanic Origin: 1999 to 2100 (Middle Series). Washington, DC: U.S. Census Bureau. Available at http://www.census.gov/population/www/projections/natdet.html.Source: R. Friedland and L. Summer, Demography Is Not Destiny, Revisited, The Commonwealth Fund, March 2005.

Note: The total population data for 1900 to 2000 include unknown age data. Therefore, the data used to determine the proportionof the population under age 65 and age 65 and older does not sum to equal the total population.

7692

404

377

351

325

300281

249227

203

179

151132

123106

A Youth Bulge

• The world is in a demographic transition – from high rates of fertility and mortality, to lower birthrates and longer lives.

• But since mortality rates are falling before fertility rates are, a “youth bulge” results.

• We need new designs to ensure the health of these growing populations.

Southcentral Foundation, Anchorage, AK

The “Five Year Gestation”

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%




No Data <10% 10%–14%




No Data <10% 10%–14% 15%–19%




No Data <10% 10%–14% 15%–19% ≥20%




No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

The “Hot Spots”

• “Super” utilizers of health services

• 5% of patients account for 49% of US health spending

• Patients at the end of life need improved palliative and hospice care

Our Challenges




Increasing Complexity

• In the mid 1970s, the average patient in a hospital required 2.5 staff FTEs for care…

• …20 years later, the average patient needs 19.5 FTEs†

• A physician today has over 13,600 possible diagnostic options and the opportunity to select from over 6000 prescription options in the US

†Source: Atul Gawande, MD

The Path Forward

• New ways to lead

• Vibrant and important aims

• More ways to learn

The Four Leadership Questions

• Do you know how good you are?

• Do you know where you stand relative to the best?

• Do you know where the variation exists?

• Do you know the rate of improvement over time?

New Leadership Skills

PersonalLeading Through:• Attention• Listening• Sensing• Learning• Action• Signs and symbols

StructuralLeading With:• Patient-led design• Structural huddles• Gemba walks• Cultural changes

– Safety– Harm– Patient-centered– Improvement and

innovation• Spread strategy• Building capability

Structured Huddles

• A huddle is a “communication vehicle…a fast, focused, highly collaborative process.”†

• Huddles should be frequent and short.

• They enhance communication; generate and help manage knowledge; and help continuously improve care delivery.

†Cooper, Robert L. Meara, ME. “The Organizational Huddle Process – Optimum Results Through Collaboration.” Health Care Manager: December 2002.

Huddlesat Cincinnati Children’s Hospital Medical Center

Gemba Walks

Ghana: Rapid scale-up of systems improvement across nation’s health facilities

Project is ahead of schedule, with simultaneous spread in northern regions (NCHS and Ghana Health Service) and middle regions (NCHS hospitals Collaborative).

The Path Forward




Experience of Care

Per Capita Cost

Health of a Population

Institute of Medicine’s Six Aims

• Safe – no needless deaths• Effective – no needless pain or suffering• Patient-Centered – no helplessness in

those served or serving• Timely – no unwanted waiting• Efficient – no waste• Equitable – for all

Patient-Centered Flow • Patient demand is growing• Our ability to safely and

efficiently serve all patients depends on:– Right Patient– Right Place– Right Time– Right Care Team– No Delays

• Most activity in the hospital is scheduled; urgent/emergent work is “predictable”

Flow and Safety• Inseparable initiatives in a hospital

• Getting the “Rights” right– Right Bed, Nursing Care, Time, Plan, Treatment

• No longer a passive system – best care requires active management of these critical aspects of the patients experience.

• Best route to optimize the best care model is to control the variables in care delivery.

Initial Results of Re-Design

• Weekday Waiting Times – 28% reduction in spite of a 24% increase in case volume

• Weekend Waiting Times – 34% reduction in spite of a 37% increase in case volume

• Throughput increase of 4.8% = 1 OR room in a setting of 20 rooms

• Overtime hours decreased by an estimated 57% between September 18, 2006 and the first week of January 2007. If OR operating costs are estimated at $250/room hour, then these savings are equivalent to $10,750/week, or $559,000 annually.

• Overall growth sustained at ~7% / year for past two years, no additional operating rooms added

Greater Production Capacity Through Flow and Patient Placement – What Has it

Meant?

• Has allowed for an additional 78 patients per day to be treated within our current bed capacity that would not have been possible under “pre-flow improvement processes

• Improved flow and patient placement have allowed us to avoid the construction of 102 additional beds ($100+ million) that would have been required to meet today’s volume in our FY2002 workflow system

Institute of Medicine’s Six Aims

• Safe – no needless deaths• Effective – no needless pain or suffering• Patient-Centered – no

helplessness in those served or serving

• Timely – no unwanted waiting• Efficient – no waste• Equitable – for all

How do we make care more patient centered?

The Burden of the Illness

Innovation: Learning from Patients

The Old Way• Ryhov Hospital in Jönköping had traditional hemodialysis

and peritoneal dialysis center.• But in 2005, a patient, Christian, asked about doing it

himself.

The New Way

• Christian taught a 73-yr-old woman how to do it…

• …and they started to teach others how to do it.

The New Way

• Now they aim to have 75% of patients to be on self-dialysis

• They currently have 60% of patients

Lessons to Date

• From Christian (patient):─“I have a new definition of health.”─“I want to live a full life. I have more energy

and am complete.”─“I learned and I taught the person next to me,

and next to her. The oldest patient on self-dialysis is 83 years old.”

─“Of course the care is safer in my hands.”

Lessons to Date

• From Anette (nurse leader):─ Surprised at design differences between patients,

family, and staff─ Managing at 1/2 – 1/3 less cost per patient─ Evidence of better outcomes, lower costs, far fewer

complications and infections─ “We brought in the county’s employment, helped the

patients make or update the CVs, and trained them for a new career.”

Lessons to Date

• From Britt Mari (nurse and innovator):─Found courage to say “yes” in the patient’s

face─“We used the same training program as I use

for new nurses.”─“The patients are our partners in designing

the unit, buying equipment, teaching, and planning.”

Lessons to Date

• From Ingrid (nurse):─“I got the courage to change (after 40 years)

because I saw the patients ‘lift up.’”─“I moved from being a technical expert to a

coach.”─“The patients are so fit, always exercising

while they treat.”

Experience of Care

Per Capita Cost


Henry Ford Health System

Harm Issue Total Associated Costs Pressure Ulcer stage 2 or higher $10,624,410

Coded Procedural Complication ICD9 (998-999.99) $7,670,520UTI using coded data and AHRQ definition. $5,662,895Glucose below 40 $3,846,375Coded Acute Renal failure $2,665,680

Coded DVT/PE in both medical and surgical patients $2,365,470No Pulse Blue Alert $1,535,808Coded Medication issue $1,216,078Clostridium difficile infection $824,544Reported Fall with injury $696,527Bloodstream Infections using NHSN criteria $640,000Coded Pneumothorax using AHRQ definition $340,260SSI using NHSN criteria $280,000VAP using NHSN criteria $190,352

Total Harm-Associated Costs 2009*

*Henry Ford Hospital Only

Removing Waste

• Dr. Patty Gabow at Denver Health, a safety-net system, introduced a waste reduction focus several years ago.

• Her team has reduced expenses there by $71M, $30M in the last year – she said, “We’re getting good at getting better.”

Waste Identification Tool

http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/HospitalInptWasteIDTool.htm http://www.ihi.org/IHI/Results/WhitePapers/HospitalInpatientWasteIDToolWhitePaper.htm

http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/HospitalInptWasteIDTool.htm

http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/HospitalInptWasteIDTool.htm

http://www.ihi.org/IHI/Results/WhitePapers/HospitalInpatientWasteIDToolWhitePaper.htm

http://www.ihi.org/IHI/Results/WhitePapers/HospitalInpatientWasteIDToolWhitePaper.htm

Experience of Care

Per Capita Cost


Ideal Collaboration Between Patients and Providers

• The greatest, untapped resource for improving health care is the knowledge, wisdom, and energy of the individuals, families, and communities who face challenging health issues in their every day lives.

• People must be engaged as co-producers of health care for themselves and their communities, not merely as patients or consumers of services.

• Local communities must retrieve their own historical, cultural, and religious traditions of health and healing, and bring those into dialogue with contemporary medical systems.

-Bill Doherty University of Minnesota

Cooking class

Healthiest cafeteria

Walking bus

Camp

Nutritionist

Dentist

School nurse

Jönköping County Obesity Initiative

SalutogenesisAaron Antonovsky

From the Latin “salus” which means health, and the Greek “genesis” which means origin.

A “health-ease” instead of a “dis-ease” continuum

The Path Forward




Live Case Visits

• Powerful tool for showing the gap between current performance and the best

• Visitors study an exemplar’s (host’s) processes from the inside─ Interview staff─ Reflect on challenges they face at their home

organizations, ask the hosts how they have overcome barriers to change

Live Case Visits

• Visitors regroup and plan their strategy for the return home

• Visitors then meet with hosts at the end of the visit to reflect on what they observed, and how this informs their strategy for their organization

• Hosts offer advice, guidance, and feedback on visitors’ strategy

Live Case Visits

IHI Open School

IHI Open School Chapter Community

365Chapters

US Chapters in 46 statesInternational Chapters in 50 countries

IHI Open School Measures

• 68,000 students and residents registered on IHI.org

• 9,000 faculty and deans registered on IHI.org

• 27,000 students and residents have completed an online course

• 1,900 students and residents have earned their Certificate of Completion

* Since the IHI Open School was created in September 2008

Celebrating Successin the UT System

• Reliable processes with great tempo• Physician engagement• Multidisciplinary teamwork• Financial connections• Progress!

Promising Improvementsin the UT System

• Improved patient access at MD-Anderson’s Neuro-Interventional Ultrasound (NIR)

─Average time to next appointment decreased from over 25 days to 1 day

─Available appointment slots increased from 38 to 55


• Decreasing duration of mechanical ventilation at Parkland Health and Hospital system

─Mean duration of mechanical ventilation in the MICU decreased from 6.1 days to 4.0 days

─Ventilator-associated pneumonia rate reduced by 52%


• Reducing avoidable harm in the medical ICU at UT Southwestern University Hospitals Dallas

─Health care-associated infections (HAIs) fell from 63 in 2009; to 32 in 2010; and to 21 as of August, 2011

─Patient falls with injury eliminated in MICU

Thank You!

Maureen Bisognano

President and CEO

Institute for Healthcare Improvementwww.IHI.org

[email protected]

617-301-4800

http://www.ihi.org/

mailto:[email protected]

Leading Together Maureen Bisognano President and CEO IHI UT System Clinical Safety and Effectiveness...

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