September 28, 2016Singapore

New People, New Pl N M th dPlaces, New MethodsInternational Forum on Quality and Safety in Healthcare

Maureen BisognanoPresident Emerita and Senior Fellow

Our Leadership Challenges• Aging, and the increasing burden of chronic disease• New roles and multigenerational workforcesNew roles and multigenerational workforces• Rapid expansion of technology• Research output at unprecedented levels and speed• Increasing patient expectations for engagement• Challenges to dramatically improve safety and flow

D i i l i t t d i ti• Designing a learning system to decrease variation

The IHI Triple Aim

Innovation

• New models of care

• New sites for caring

N• New teams

• New ways to lead and governy g

Radical Redesign Principles

• Change the Balance of Power • Make it Easyg

• Standardize What Makes Sense

C t i t th I di id l

y

• Move Knowledge, Not People

C ll b t /C t• Customize to the Individual

• Promote Wellbeing

• Collaborate/Cooperate

• Assume Abundance

• Create Joy in Work • Return the Money

Comparison of In-Center Self-Care Hemodialysis to Non-Self Care

ICSCHD Non-SCHDICSCHD Non SCHDNo of pt 48 848

Crude Mortality Rate(deaths /100 pt yrs) (%)

5 18

SMR 0 23 ( 25 1 52) 1 03 (0 87 1 13)SMR 0.23 (.25-1.52) 1.03 (0.87-1.13)

Hospital days/pt yrs 7.5 14

PO4 (mg%) 5.47 5.04

Albumin >4g/dL (%) 66 52

Albumin (g/dL) 4.04 3.78

Unexcused missed Rx(%) 1.0 4.87

Employment rate : 26% vs 7% in a facility within the same buildingEmployment rate : 26% vs 7% in a facility within the same building

Edward R Jones, MD, MBA, Medical Director, Self-care FMC Mt Airy Phila.

Successful Spread - Waco, Texas

Richard Gibney

Jarle

History:– 70 year old man with COPD type 2 diabetes and two– 70 year old man with COPD, type 2 diabetes, and two

previous heart attacks– Suffered a major stroke, and spent a month in the hospital– Left side paralysis, poor cognitive and physical functionLeft side paralysis, poor cognitive and physical function

Began prescribed reablement program, which was continuously reassessed; made good progress and entered health rehabg p gCame back to reablement after challenges; they helped him find a new, more accessible apartmentNow largely independent, and needs a wheelchair only for long distances

Thomas Lystad

Reablement- Oslo Kommune, Norway• Interprofessional team who are the first to meet with new

patients in need of home-based care– occupational therapists– physiotherapists– nursesnurses – social workers

• Work towards independence and mastery of everyday life transitioning patients to either:life, transitioning patients to either: - discharge without need of further healthcare, or- home-based care with the best possible function

Thomas Lystad

CAPABLE• “Community Aging in Place, Advancing Better Living for Elders”

– Emphasizes helping older adults maintain independence through environmental adaptations and interventionsenvironmental adaptations and interventions

– Team of occupational therapist, nurse, and handyman• Common fixes:

– Installing or fixing railings or grab bars– Installing or fixing railings or grab bars– Improving lighting– Installing non-skid treads in tubs and showers– Repairing trip hazards, like holes or tears in carpet, or broken timesp g p p

• 79% of initial participants reported fewer activity of daily living limitations

Szanton, S.L., Wolff, J.L., Leff, B., Roberts, L., Thorpe, R.J., Tanner, E.K., Boyd, C.M., Xue, Q.L., Guralnik, J., Bishai, D., Gitlin, L.N.: Preliminary data from community aging in place, advancing better living for elders, a patient-directed, team-based intervention to improve physical function and decrease nursing home utilization: the first 100 individuals to complete a centers for medicare and medicaid services innovation project. J. Am. Geriatr. Soc. 63(2), 371–374 (2015).

CAPABLE

• Average price of intervention over four months: $4,000• Average monthly price of a skilled nursing facility:• Average monthly price of a skilled nursing facility:

$6,400

Szanton, S.L., Wolff, J.L., Leff, B., Roberts, L., Thorpe, R.J., Tanner, E.K., Boyd, C.M., Xue, Q.L., Guralnik, J., Bishai, D., Gitlin, L.N.: Preliminary data from community aging in place, advancing better living for elders, a patient-directed, team-based intervention to improve physical function and decrease nursing home utilization: the first 100 individuals to complete a centers for medicare and medicaid services innovation project. J. Am. Geriatr. Soc. 63(2), 371–374 (2015).

Khoo Teck Puat Hospital, Singapore

Critical Flow Failures & Percent OccupancyPopulation: Main Campus, Including College Hill

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New Critical Flow Failures Average % Occupancy During Month

Last Updated 10/23/2009 by A. Anneken, Division of Health Policy & Clinical Effectiveness

New Sites for Caring

http://www health org uk/flohttp://www.health.org.uk/flo

New Sites for Caring

• 5000 hours• Bed-less hospitals• Care at the “webside”• Health outside systems

COND  SECUNDARIOS INTERVENCIONESCOND   PRIMARIOS

2013 2013 strategiesstrategies –– ChronicChronic absenteeismabsenteeism

ASISTENCIA

COND. SECUNDARIOS

Children motivation Monthly incentive

Panel of attendance

COND.  PRIMARIOS

Chronic absenteeism address at parents’ 

School absenteeism

Aim: to reduce 

Parents diploma

pmeeting

Text message when absent

By weekly report

Aim: to reduce absenteeismby 20%

Parents’ motivation

School Director’s presence at parents meeting

Parent ideas for solutions at parents meeting

Actions by the School Leadership Team

Transportation provision

meeting

Personal interviews with parents

Name

M th

Days missed overthe last 2 weeks

Month

Number of days that thechild with the best record f i t h i dof assistance has missedover the last 2 weeks

Reminder of ‘chronic

absenteeism’absenteeism

OBESITY PREVENTIONPlan & Do

Goal:  To eliminate sugar‐sweetened beverages and increase water consumption in preschool classroomsg g p p

Sugar sweetened beverages

Water consumption

PDSA Health – Obesity preventionClassroom Centro Parvulario

Plan & DoG l T li i t t d b d i t ti i h l lGoal:  To eliminate sugar‐sweetened beverages and increase water consumption in preschool classrooms

A PS DS D

Ciclo 3: Develop simple , child-centered measurement

A PS D

Ciclo 1: Make a pitcher of water & individual cups available to children.

Ciclo 2: communicate to parents that juices and soda are no longer permitted – send home beverages sent to school

Ciclo Make a p tcher of water & nd v dual cups ava lable to ch ldren.

PDSA Health – Obesity preventionClassroom Centro Parvulario

Plan & DoG l T li i t t d b d i t ti i h l lGoal:  To eliminate sugar‐sweetened beverages and increase water consumption in preschool classrooms

A PS D Ciclo 4: Serve water with lunch

Ciclo 5: use plants to show scientific benefits to drinking water over soda

S D Ciclo 4: Serve water with lunch

Ciclo 3: Develop simple , child-centered measurement

A PS D

Ciclo 1: Make a pitcher of water & individual cups available to children.

Ciclo 2: communicate to parents that juices and soda are no longer permitted – send home beverages sent to school

Ciclo Make a p tcher of water & nd v dual cups ava lable to ch ldren.

PDSA Health – Obesity preventionClassroom Centro Parvulario

Plan & DoG l T li i t t d b d i t ti i h l l

50%

60%% de Ninos q Trajeron Jugo -- Centro

ParvulariaPercent

Goal:  To eliminate sugar‐sweetened beverages and increase water consumption in preschool classrooms

UCL

10%

20%

30%

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%

Sugar sweetened beverages

LCL0%

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PresentesRate

UCL

LCL0 5

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Leading New Teams

• Multigenerational teams

• Multiprofessional teams

• Diverse and inclusive teams

• Include patients and families

Multigenerational Teams

• Five distinct generations on our teams

• Each brings different knowledge, skills, and views

Multigenerational Teams

• Traditionalists (71 to 88 years old): loyal

• Baby Boomers (56 to 70 years old): optimists

G i X (36 55 ld) i i• Generation X (36 to 55 years old): questioning

• Gen Y, Millennials (21 to 35 years old): realistic, ( y )

• Gen Z, iGen (20 years old and younger): balanced

Changes the Next Generation Expects from Health Care

“Li f th t”• “Live for the moment”– Don’t see regular check-ups and testing as part of their health and wellness

• “Dr. Who?”o– Seek advice and care from many sources; we’ll need new ways to connect

• Holistic healthU dit ti t iti i d di i– Use meditation, massage, nutrition, exercise, and medicines

• Track me, treat me– Less concerned about privacy and expect us to track and connect to care

Multiprofessional Teams

• Learning together from the start• Building skills in teams• New ways to teachy• Using the IHI Open School as a platform for

sharingsharing

What Matters to Patients

Moving fromg“what’s the matter?”

to“what matters to you?”

Barbara78 year old woman admitted to an NHS hospital after falling at home.Lived alone, but had frequent visits from carers and was mobile.Became withdrawn in hospital; medical staff considered antidepressants and a nursing homeBecame withdrawn in hospital; medical staff considered antidepressants and a nursing home

upon discharge.

“What matters to me” displayed above her bed led to conversation:Lived in Rio de Janeiro for 42 yearsLived in Rio de Janeiro for 42 yearsSpoke fluent PortugueseHad been in the Women’s Air ForceHad an MBE (Member of the Most Excellent Order of the British Empire)Had an MBE (Member of the Most Excellent Order of the British Empire)

The staff saw Barbara with all of her assets. She began to work well with therapists, and was discharged to her own home.

“How long have you lived in San Francisco?”

“Where did you come from?”

“Years and years”

“Ireland”Where did you come from?

“When did you come?”

Ireland

“1912”

“Have you ever been in the hospital before?”

“How did that happen?”

“Once, for a broken arm”

“A trunk fell on it”

“A trunk? What kind of trunk?”

“How did that happen?”

“A steamer trunk”

“The boat lurched”How did that happen?

“The boat? Why?” “It hit the iceberg”

“Oh! What was the name of the boat?” “The Titanic”

Fitzgerald, Faith T., MD. "On Being a Doctor: Curiosity." Annals of Internal Medicine 130.1 (1999): 70-72.

The Patient as a Teammate“What’s a good day for you?”

New Ways to Lead and Govern

• New attention to the data• New ways to engage staff• New ways to engage staff• Build improvement capability and innovation/harvesting

processprocess• Community connections• Move upstream and downstream• Move upstream and downstream

New Ways to Lead and Govern

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 you stand relative to the best?

• Do you know where the variation exists?

• Do you know the rate of improvement over time?

The Importance of Curiosity

• IQ – Intelligence Quotient– processing complex data sets and having the mental capacity to problem solveprocessing complex data sets and having the mental capacity to problem solve

at speed

• EQ – Emotional Quotient– the ability to perceive, control and explain emotions; risk-taking, creating

resilience and empathy

• CQ – Curiosity Quotienty– inquisitive, open to new experiences, finding novelty exciting

Chamorro-Premuzic T. “Curiosity Is as Important as Intelligence.” Harvard Business Review. Aug 27, 2014.

What Matters to Staff

• Mastery: continuous focus on the skills and expertise needed in today’s complex settingsneeded in today s complex settings

• Community: deliberate mechanisms to build camaraderieCommunity: deliberate mechanisms to build camaraderie

• Mentorship: attention to growingp g g

Leading: Use Data to Predict and Plan for Hiring

P hi i• Pre-hiring• Boomerangs• Alumni networks• “Returnships”p• COMPASS

450,953 students and residents registered on IHI.org

338,501 students and residents have completed over , p2.3M courses

76 692 students and residents have earned their Basic76,692 students and residents have earned their Basic Certificate of Completion

814 h t i 84 t i814 chapters in 84 countries

IHI’s MOOC with Harvard• IHI developed its own MOOC, Practical Improvement Science in Healthcare: A

Roadmap for Getting Results, in collaboration with HarvardX and the Harvard T H Chan School of Public HealthT.H. Chan School of Public Health.

• CME accredited for pharmacy, medicine, and nursing • Future courses in development:

organizational change– organizational change management/leadership

– qualitative and quantitative improvement and researchpmethods

– systems engineering – IT-enabled improvement

Innovation: Northern Ireland Leaders in our Sandbox

R&D 90-Day Projects (2015-2016)WAVE 34

Systems of SafetyOptimized Access and FlowMaternal and Child Health

WAVE 35Revisiting the Juran TrilogyMaternal and Infant HealthAccess to the “Right” CareMaternal and Child Health

Leadership Alliance100M Healthier Lives

Access to the Right CareSafety Across the ContinuumHealth Disparities

WAVE 36E it P t II

WAVE 37Equity Part IIMaternal/Infant Health- Part IIAccess and FlowSafety Testing: Medication Testing and Framework Evaluation

Hospital FlowPrimary Care AccessHow to Create a Joyful WorkforceDecreasing Systemic Racism in Health Care Whil M ki H lth E it S t ’Collaborating Improvement

MethodsImproving Front Line Management

While Making Health Equity a System’s PropertyA Triple Aim Approach to Maternal and Infant Health – Part IIIThe “How” of National Quality StrategiesAddressing the Opioid EpidemicDeveloping the Business Case for Complex Needs Patients

Joyy

She who laughs, lasts.

Thank You!Maureen Bisognano

President Emerita and Senior FellowInstitute for Healthcare Improvement20 University Road, 7th FloorCambridge, MAmbisognano@ihi.org