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NTI2010 Increasing Quality And Safety
- 2. Increasing Quality & Safety in Your Organization: Utilizing IHI’s Seven Leadership Leverage Points Todd M. Grivetti, MSN, RN, CCRN, CNML Clinical Nurse Manager Regional Neurosciences Center Poudre Valley Hospital Ft. Collins, CO.
- 5. About Me
- 42. Standardizing Clinical Processes: Typical Approach Design Design Design Design Approve Conference Rooms REAL WORLD Implement
- 43. Standardized Clinical Processes: Refine the Design using Small Tests of Change Design Conference Rooms Approve (if necessary) Real World Test and Modify Test and Modify Test and Modify Implement
- 46. Sample Implementation Process Source: StuderGroup.com (2005)
- 51. 15 minute Break Yampa Valley near Steamboat Springs, CO. 2009 Photograph by Todd Grivetti ©
- 52. Leadership Leverage Points Self-Assessment Tool for System-Level Results Board has adopted the aims and is overseeing their achievement using system-level measures of progress against the aim. Senior Leadership team has developed specific “how much, by when” aims for system-level measures of quality and safety. 1. Establish and Oversee Specific System-Level Aims for Improvement at the Highest Governance Level By When By Whom Action Needed / Action Planned Leadership Leverage Points
- 53. Leadership Leverage Points Self-Assessment Tool for System-Level Results Senior Leadership team has resourced the projects that are necessary to achieve the aim with effective leaders. Senior Leadership team has developed a plan to achieve the aims that is focused on the right drivers, and had the necessary scale and pace. 2. Develop an Executable Strategy to Achieve the System-Level Aims and Oversee their Execution at the Highest Governance Level By When By Whom Action Needed / Action Planned Leadership Leverage Points
- 56. Improving & Executing System Level Change Utilizing Leadership Frameworks & Toyota Production Specifications
- 66. Achieve Strategic Goals Manage Local Improvement Build Capability ENVIRONMENT INFRASTRUCTURE Spread and Change Provide Leaders for Large System Change Spread and Change Provide Leaders for Large System Projects Provide Day to Day Leaders for Microsystems Core Elements for Process Improvement
- 70. “ It is Leadership’s job to build the will for change among busy professionals, implement systems to capture new ideas and spread them to the right people within the organization, and design and implement an effective strategy” Bisognano, Schummers, McCannon
- 71. Whole System-Measures and Toyota Specifications – System Level Whole System Measures and Toyota Specifications: System Level. IHI, 2008 $3,000 per capita Per capita health care expenditures Efficient 5% of Adults self-rate their health status as fair or poor. (Response rate will not differ by income) Self-Reported health status Effective and Equitable 72% of Patients report, “They give me exactly the help I want (and need) when I want (and need) it.” Patient Experience Score ( Response to the question in the How’s Your Health Database, “They give me exactly the help I want (and need) exactly when I want (and need) it.” Patient Centered Toyota Specifications Whole System Measure IOM Dimension of Quality
- 73. Whole System-Measures and Toyota Specifications: Component Level HSMR = 57 Hospital Standardized Mortality ratio (HSMR) Effective Care Primary Care: Same Day Access Specialty Care: Within 7 Days Days to third next available appointment Timely Access to Care 5 Adverse events per 1000 pt. days Adverse Events per 1000 pt. days Safe Care Reliability Levels 10 2 Pervasive Reliability Evidence Based Care Performance Specifications Measure Dimension
- 75. Whole System-Measures and Toyota Specifications: Component Level 81% of Patients are Satisfied Patient Satisfaction Patient – Centered Care $5,026 per enrollee Medicare Reimbursement Efficient Care 7.24 Hospital Days per Decedent during last six months of life Hospital Days per Decedent during the last six months of life Efficient Utilization and Resource Use 0.2 Cases with lost work days/100 FTE’s/Year Occupational Injuries and Illnesses Safe Work Place 30-Day Hospital Readmission = 4.69% Hospital Readmission Percentage Effective Care that Crosses Barriers HSMR = 57 Hospital Standardized Mortality ratio (HSMR) Effective Care Primary Care: Same Day Access Specialty Care: Within 7 Days Days to third next available appointment Timely Access to Care 5 Adverse events per 1000 pt. days Adverse Events per 1000 pt. days Safe Care Reliability Levels 10 2 Pervasive Reliability Evidence Based Care Performance Specifications Measure Dimension
- 82. Step 3: Key Stakeholders/Customers Who may be affected by changing of the current state? Example: Specific departments, people, customers Step 4: Context (External, Internal Factors Driving the Need for Change) Example: Why would changing from the current state matter? Step 5: Approaches/Actions What possible ways could this issue be resolved? Example: Education program, change in policy, PDCA team, brainstorming Strategic Conversations Step 1: Current State What is the current situation that is driving the change? Example: What is not occurring? Step 2: Future State What would be the ideal situation after the change? Example: That particular “something” would be occurring.
- 84. Whole System-Measures and Toyota Specifications: Component Level 81% of Patients are Satisfied Patient Satisfaction Patient – Centered Care $5,026 per enrollee Medicare Reimbursement Efficient Care 7.24 Hospital Days per Decedent during last six months of life Hospital Days per Decedent during the last six months of life Efficient Utilization and Resource Use 0.2 Cases with lost work days/100 FTE’s/Year Occupational Injuries and Illnesses Safe Work Place 30-Day Hospital Readmission = 4.69% Hospital Readmission Percentage Effective Care that Crosses Barriers HSMR = 57 Hospital Standardized Mortality ratio (HSMR) Effective Care Primary Care: Same Day Access Specialty Care: Within 7 Days Days to third next available appointment Timely Access to Care 5 Adverse events per 1000 pt. days Adverse Events per 1000 pt. days Safe Care Reliability Levels 10 2 Pervasive Reliability Evidence Based Care Performance Specifications Measure Dimension
- 90. Conclusion Thank you ?Questions?
Notas del editor
- Reference PHVS’s GPS model – MVV, Strategic Objectives, Planning and aligning, Executing Plan, Development
- Establishing system-level performance helps answer two questions. What are we trying to achieve How are we doing at it? These two main questions really summarize How Good We Are .
- Reference Performance Improvement Committee’s based on Malcolm Baldrige – 7 Teams: Leadership Team Strategy Team Customer Service Steering Committee Knowledge Management Team Workforce Team Process Improvement Team Key Measures Team
- This type of system ensures that leaders take timely action to resolve issues that may be prohibiting execution (e.g., break down barriers, provide resources for project leaders, or replace project leadership). If the project is well executed, and little progress on system-level is seen, the senior team must take action to revise the strategic project portfolio. This can be accomplished through multidisciplinary teams, PDCA team or Quality Improvement processes utilized in your institutions.
- The most commonly cited reason for failure of organizations to reach breakthrough aims is the failure of the senior leadership group to function as an effective team, with the appropriate balance of skills, health relationships, and deep personal commitments to achievement of the goals. Most important is that these principles must be translated into specific structural and process changes if they are to have an effect on the organization’s culture: The most powerful of these structures and process is putting the patient in the room Self-Serving Conversations cease – Many complaints (e.g., “We can’t do it that way because that would require us to cooperate with that other cardiology group which we compete with”) sound unseemly when patients and families are in the room. The whole system of Care Comes into Play: Patients experience care across mulitple departments, medical groups, and organizations. They want solutions that work for them, not just for one part of the system. Better, more Innovative Ideas come forward: Patients and families are a tremendous wellspring of ideas for improvement and redesign. Physicians and Nurses feel supported and inspired: When patients are on committees and task forces, they become a source of energy and positive reinforcement for care professionals.
- Organizations are now beginning to understand the financial impact of harm events such as falls, medication errors, and delayed care are having. Utilization of Evidence Based care protocols are demonstrating a significant cost reduction when utilized. Eliminating errors and clinical waste also have a significant impact in cost savings. Cost reduction efforts commonly have been a reaction to external changes in the market or payment systems and are generally one-time events focused on: Reducing the cost of labor Reducing the cost of supplies Changing vendor contracts Compared to other CFO’s in other industries, health care CFO’s typically do not focus on improving the processes themselves – Taking out wasted time and effort Eliminating defects that require rework. The core process of health care – diagnosing, treating and communication with patient has been a “Black Box” and off limits to CFO’s
- Strongest Examples of Leverage Point Five: Virginia Mason Medical Center, Washington Park Nicollet Health Services, Minnesota Using Lean techniques – Process 64 patients daily through their same day endoscopy facility that once struggled to care for 30 – 32 patients daily. $3 million in capital expenditures were avoided by utilizing Lean methodology ThedaCare, Wisconsin Extensive reduction in waste in their first couple years of operation by utilizing Lean methodology – CFO built a long-range financial plan that does not require any price increases. McLeod Regional Medical Center, South Carolina Eliminate 112 minutes of wasted nursing documentation time per cardiac patient, thus freeing up nursing to provide higher levels of quality and safety. All have adopted lean management principles (Toyota Production System)
- Physician Engagement: At PVHS – 2009 Gallup poll taken by physicians – placed their level of engagement in the 96 th Percentile. Equally, physician-nurse communication/collaboration was ranked in the 96 th percentile as well.
- 1.1 The key idea is to learn what the physicians’ quality agenda is and harness the organization’s quality efforts to their agenda. Physicians are less excited about improving the hospital’s publically reported data, reducing length of stay or removing waste in the supply chain – “Not my problem, it’s the hospitals” 1.2 Physicians care about mortality and harm – quality and safety outcomes. One way to engage them is make sure that organization’s aims focus on outcomes meaningful to physicians. Example: Instead of being in the top 10 th percentile of CMS Core Measures – Aim for “reducing the risk of needles deaths in the hospital.” One strategy might be to improve the reliability of CMS Core Measures for acute myocardial infarction and pneumonia. Another might be to increase the amount of smoking cessation education provided to patients or the development of Centers of Excellence
- Reframe Values and Beliefs Organizations need to reexamine and reframe some of their core values and beliefs if true engagement in quality and safety is to occur. Doctors must begin to see their responsibility for the system’s quality results, and not just for their own personal quality performance. One example of redesign is the traditional “Morbidity and Mortality Conference”. In general this conference asks “Did someone make an error of judgment or of technique in this case?”. The new redesigned process requires physicians and administrators to ask the following question: “ What were the systems factors – culture, structure, processes that contributed to this death and what can we do together to change these factors?” Ask Physicians what they need.
- Team – Should be about 10 members including those who work closely with physicians (major nursing units, medical office staff, high volume outpatient departments and admitting) Data – Information from physician satisfaction surveys – (Thomson Reuters, AVATAR, Gallop) is utilized as a springboard for brainstorming for optimal environments for physicians. Goals – Set 90 day action plan is shared with leaders. Monthly targets are set along with outcomes for the year.
- Reframe Values and Beliefs Organizations need to reexamine and reframe some of their core values and beliefs if true engagement in quality and safety is to occur. Doctors must begin to see their responsibility for the system’s quality results, and not just for their own personal quality performance. One example of redesign is the traditional “Morbidity and Mortality Conference”. In general this conference asks “Did someone make an error of judgment or of technique in this case?”. The new redesigned process requires physicians and administrators to ask the following question: “ What were the systems factors – culture, structure, processes that contributed to this death and what can we do together to change these factors?” Ask Physicians what they need.
- 3.1. Not all physicians need to be engaged in any particular quality initiative. Those who are engaged do not need to be engaged in exactly the same way. 3.2. Plan segmentation through physician champions, physician members of the actual improvement team, structural leaders of the medical staff who might need to adopt a new policy. 3.3. Engage those physicians who are more likely to “block” recommendations that emerge from the project team or policies recommended by the structural leaders.
- 4.1. Physicians are often cynical about quality improvement based on methods utilized in the past that really disengaged them previously. (Example: Don’t ask physicians to join improvement teams that meet twice a month during times when physicians are making rounds; utilizing the time for activities that do not require physician input; gathering data without testing any changes, then sending out flawed performance data on quality measures asking them to improve on it). See fig’s. Next slides on what this process looks like and what it should look like.
- As a guideline, use small tests to refine the design for the local setting. Do not spend more than one meeting on the WHAT of a guideline. There are relatively good “Starter Kits” for a clinical guideline or protocol available from a national, reputable source. Do not spend time reinventing the wheel or the science behind the project. Focus on how to make the exiting protocol work within the local context. The TEAM tests various methods for the how, who, when, where , initially on a very small scale, making frequent changes to improve implementation. Tests of change increase in scale, until most physicians find themselves able to use the protocol in their patient care, at which point the protocol is adopted with the expectation that physicians opt out if they do not wish to use it.
- 5.1. Change is required to make improvements in quality and safety, yet it is often met with set back through what is called Monovoxoplegia or “paralysis by one loud voice.” Physicians are among the most powerful voice in healthcare organizations and their collegial nature makes them reluctant to challenge other physicians. This paralysis is common place in physician meetings, improvement teams, executive teams and even board rooms, where lay members sit silent when one physician speaks up against a proposed change. There is no simple solution to Monovoxoplegia , however, the basis of an effective approach relies on building an organizational culture of courage – The Courage to ask questions The Courage to challenge the status quo The Courage to support the physicians and nurses WHO do wish to make improvements. Courage could be illustrated best by Donna Isgett from McLeod Regional Medical Center and the question she asks physicians when they balk at Evidence Based Practice. “Are you saying that you value your individual autonomy more than you value your patient’s outcomes?” Knowing they will be supported all the way to the board enables all clinicians, including physicians to ask tough questions… Courage is infectious
- 6.1. When involving physicians – don’t hand them a final or near-final version of proposed changes and expect acceptance. 6.2. Work with real leaders – Usually there are one or two opinion leaders. Although they might not be leaders within the organization per se’ they have earned the respect of their peers and have the ability to influence others. These leaders MUST be involved in the improvement changes. 6.3. Choose messengers and messages Carefully: Credibility is generally view as credible by the whom delivers the message, so it is important on who delivers the message (specialist, general practitioner, or someone with specific specialty certifications. Communication should be designed to be engaging rather than inflammatory. 6.4. Be Transparent, especially with data – Physicians usually do not trust interpreted data. Give them access to raw data. Even if they do not look at the data, they will value knowing that you trust them to do so. 6.5 Value Their time with you Time:
- The self assessment should be completed by senior leadership – initially as individuals, then as a team in order to review results and action plans
- Continue completing all 7 Leverage points with action plans.
- Customer Services & Patient/Family Center Care – PVHS Team committee:
- PVHS – Customer Service Steering Committee
- Organizations that are to consistently improve system-level performance will have capabilities in three areas: System-Level Aims, Local management and supervision, and development of sufficient number of employee’s:
- This slide represents the differences between the Institute of Medicine and TPS based on Cost per capita for severely ill persons with multiple chronic diseases.
- Pitfalls – Often encounter resistance to the ambition of the goal. Response: Reduce the ambition of the goal by moving to a lower level in the system that requires less integration (Cost per case in a hospital, rather than total costs With many opportunities for improvement, setting too many goals will underscore the ambitions. Typically leading to under-resourcing. The goal for organizations now is to look at the future of healthcare. Suggestions: Keep discussions centered on the patient’s experience over time Use the Toyota specifications as a comparison for the level of ambition Concede that one project may not be sufficient to accomplish the goal
- HSMR – is the calculation used to compare a hospital’s actual mortality rate to the risk-adjusted expected mortality rate
- HSMR – is the calculation used to compare a hospital’s actual mortality rate to the risk-adjusted expected mortality rate Discuss Fall Program/protocol and video monitoring – Graph? Patient-Family Center Care @ PVHS
- IHI’s 100,000 Lives Campaign as well as 5 Million Lives campaign are two strategic goals adopted by 3,700 hospitals and health systems. Stories of PVHS – Malcolm Baldrige Teams-
- Utilization of the Rapid Cycle PDCA’s (PDSA) can implement change in a shorter period of time. These are not meant to be dragged out 6-10 months, but 3-6.
- HSMR – is the calculation used to compare a hospital’s actual mortality rate to the risk-adjusted expected mortality rate Discuss Fall Program/protocol and video monitoring – Graph? Patient-Family Center Care @ PVHS