Change Management In Healthcare Quality -...
Transcript of Change Management In Healthcare Quality -...
Imagination at work.
17 August 2015
Change Management In Healthcare Quality
Privileged & Confidential
Oghogho Olakunri
GE Healthcare Partners - EAGM
2 GE Title or job number
8/17/2015
What contributes to poor quality in Healthcare?
“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”
Quality of care is…
— Institute of Medicine, 1990
Merely making health services accessible does not ensure they will be utilized Research in many settings has shown that demand for immunizations and other primary health care services rises with the quality of those services To attain and maintain healthy populations, countries must find ways to improve the quality of care on offer
Why emphasize quality of care?
Six Aims of IOM:
I. Safe II. Effective III. Patient Centered IV. Efficient V. Timely VI. Equitable
What is HIGH QUALITY care?
http://youtu.be/5vOxunpnIsQ 5
What is HIGH QUALITY care?
Safe • We are not harming people with our care
• We are not adding to the burden of illness
Effective • Matching science to care
• Avoiding overuse of interventions that don’t help, ensuring use of those that
help and avoiding underuse
Patient-centered
• People should be in control of their own care
• They should make decisions about what affects them
• Nothing about me without me
Timely • Avoiding delays
• Reduction of non-instrumental delay
Efficient • Avoiding waste including waste of equipment, supplies, ideas, and energy
Equitable • Justice in healthcare
• Care quality should not vary based on socioeconomic status, geographical
location, gender, religion etc
Healthcare needs to improve in these six areas
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Donabedian Quality of Care Framework
The most common quality of care framework
• The context (structure) in which care is delivered affects processes and outcomes
• Outcomes indicate the combined effects of structure and process
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Structures Processes Outcomes
the attributes of
settings where care is
delivered
whether or not good
medical practices
are followed
impact of the care on health status
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The Nigerian Healthcare System
•Federal Ministry of Health
•National health policy
•Policy planning
•Policy guidance
•Tertiary care, Teaching hospitals
•State Ministries of Health
•Health management boards
•Secondary care, state hospitals
•Local Government Secretariat
•Basic health services
•Community health, hygiene and sanitation
• Responsibilities for healthcare split between three layers
of government (Federal, State & Local Govts)
• Healthcare system based on the principles of three tiers:
primary, secondary & tertiary healthcare
• Healthcare provided by government, social & private
sectors
• Poor quality services across spectrum in Diagnosis,
Experience & Outcomes
• Massive loss of confidence in healthcare system
• Household out-of-pocket expenditure constitutes
majority of healthcare expenditure
• Majority of the population look to private sector for
their healthcare needs
Tertiary 56 hospitals
Secondary 1200 hospitals
Primary 10,600 PHCs
Despite growth, health indices & outcomes remain poor
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Maternal Mortality
• 560/100,000 live births • 40,000 women each year • 14% of the global total
Infant Mortality
• 78/1,000 live births
• >500,000 deaths per year
• 11% of the global total
• 70% are preventable
Under-five Mortality
• 124/1,000 live births
• >800,000 deaths per year
• 13% of global total
Supply Side
• Infrastructure/Utility deficit
• Commodity stock-outs
• Equipment inadequacy
Demand Side
• Low for critical services
• Loss of confidence in system
• 38% women deliver with skilled provider
Health Facilities
• 23,000 (est 14,000 PHCs)
• Variable functionality/poor
• Shortage of human resources
•
Source: WHO Global Health Observatory Data Repository; WHO Country Health Profile; United Nations Child Mortality Report, 2013
Disease burden drivers
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107885
32997
15072
57486 19086 21624
2621 7099
3355 5353
972 2281 2546 2588
4500 3712
8673
2835 3564
Injuries
NCDs
CMPN*
2012 CMPN: Communicable, Maternal, Perinatal and Neonatal conditions
Infections/ Parasitic
Respiratory infections
Perinatal Maternal Nutrition
Other unintentional injuries
Intentional injuries RTAs
Neuro- Psychiatric
CVD Sense organ disorders
Resp Cong anomalies
Cancers Digestive Diabetes / Endo
Communicable, maternal, perinatal and neonatal conditions predominant
0
5000
10000
15000
20000
25000Communicable, Maternal, Perinatal & Nutritional Diseases (2012)
0
1000
2000
3000
4000
5000
6000Non Communicable Diseases (2012)
Prevalence of non-Communicable Diseases (NCDs) rising
12 GE Title or job number
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How do we improve Quality in Healthcare?
Clinical Governance
A framework through which organizations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish
Clinical Governance is intimately tied to Clinical Quality
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Value proposition….simply put….better patient care
2003
“American Healthcare gets it right 54.9% of the time”
The Quality of Health Care Delivered
to Adults in the United States
McGlynn et al, New England Journal of
Medicine, 2003, 348 (26):2635-45 June 26
1912
“For the first time in human history, a random patient,
with a random disease, consulting a doctor, chosen at random, stands a better than
50/50 chance of benefiting from the encounter”
Lawrence J. Henderson MD Harvard Professor of Medicine, Biochemistry and Chemistry,
1912
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Integrated Governance
Corporate Governance Clinical Governance
Financial Ownership/shareholders Board of directors Creditors Financial/Institutional regulators
Education and Training Clinical audit Clinical effectiveness R&D Openness Risk management Information Management
The elements of clinical governance
Elements of Clinical Governance
18 GE Title or job number
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ED Attendance
Triage
OPD Clinic
Pre-op Assessment
Surgery
Discharge
My Pain and Anxiety were Quickly Managed
My surgery started on-time
My Doctor explained my test results clearly
I knew what I had to bring and do on the
day Someone was always
with me
My doctor explained my progress day by day
I was discharged on-time
I understood the risks and felt like I will be in safe hands
I had an appointment within a week
Post-operative Recovery
In-patient Ward
Admission
I knew how long I had to wait
My privacy was always
maintained
I was welcomed warmly
The surgical team
introduced themselves
My Family was kept well-informed
My nurse regularly
checked on me
I was offered information about what to expect for my surgery
The clinic was very easy to find
I was provided clear information about my
medication, follow-up and side-effects
A Snapshot of a Patient’s Journey & Perspective
The Four Evils of human behavior
When there is general agreement that the individual should have done other than what they did, and in the course of that conduct inadvertently causes or could cause an undesirable outcome, the individual is labeled as having committed an error.
Or gross negligence, involves a higher degree of culpability than negligence.
Reckless conduct differs from negligent conduct in intent: recklessness is a conscious disregard of a visible, significant risk.
Failure to exercise the skill, care, and learning expected of a reasonably prudent health care provider
The intentional rule violation occurs when an individual chooses to knowingly violate a rule while he is performing a task.
Human Error Negligent Conduct
Reckless Conduct Intentional Rule Violation
The Swiss Cheese Model
Source: Ian D Coombes, Danielle A Stowasser, Judith A Coombes and Charles Mitchell. Why do interns make prescribing errors? A qualitative study MJA 2008; 188 (2): 89-94. Adapted from J. Reason’s model of accident causation
The Swiss cheese model for clinical errors
Reducing risks patients involves: • Identifying common errors in service delivery
• Understanding the factors that contribute to these errors
• Learning from errors and complaints
• Taking action to prevent a recurrence of harm
• Putting systems in place to reduce risks
Minimizing risks that health workers are exposed to involves: • Ensuring that healthcare workers are
immunized against vaccine-preventable
infectious diseases • Ensuring that the work the environment in
hospitals is safe
• Continuous sensitization of health workers on
the need to minimize exposure to risks as well
as monitoring for compliance
Reducing risks to hospitals involves: • Sticking to the best possible employment
practices
• Ensuring that the hospital environment is
safe
• Implementing policies on public involvement
in healthcare delivery processes
1. Elements: Education and Training
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How does an institution ensure high quality
care through education and training?
Qxn:
Elements: Education and Training
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• Establishing rigor around credentialing and privileging
• Minimum CME requirements
• BLS, ACLS, ATLS, PTLS
• Availability of decision support materials and software (eg Up to date)
• All staff involved - not just physicians
2. Elements: Openness
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Blame No Blame
Open reporting in a culture of continuous improvement , not continuous blame
Example: Openness
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A hospital is trying to tackle hand hygiene across its wards and has installed disinfectant gel dispensers in convenient locations all over the hospital. However, compliance is an issue. The charge nurse on the floor is responsible for compliance and has flagged many cases in which the doctor has not complied with protocol. She feels that the doctors are the least compliant and are to blame for the recent outbreaks on the floor. However she is reluctant to report them because the doctors will get reprimands from their chairman….and they will in turn give her a hard time on the floors.
How can we overcome the lack of openness in reporting?
Some key points
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• When reporting, ensure anonymity: eg through web portal, anonymous form, and more importantly, do not make only one person responsible for reporting, it is everybody’s job.
• Have clear reporting channels and processes in place to deal with non-compliance or medical errors.
• But before reporting, encourage all staff to be “each other’s keeper”. If they see somebody doing something wrong, they should tell them without fear of repercussions.
Remember, it is all in the patients’ best interests
3. Elements: Risk Management
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Risks to patients: ensuring there are mechanisms and systems in place that minimize risk or medical error to the patient. Learning from mistakes and root cause analysis is key. Example : TIME-OUT before surgical procedure in which entire staff methodically
take time to double check patient identification and surgical site.
Risk to Practitioners: Hospitals are dangerous places. Proper protection, facilities and procedures have to be in place to safeguard your most prescious asset, your staff. Example: nov-Coronavirus (MERS) claimed a disproportionate amount of healthcare workers, which prompted strict quarantine procedures for all suspected cases.
CaradigmTM Intelligence Platform-PROTECT
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4 Days
Dashboard visualization
2 weeks
iPad Capture Tool
1 week
CIP Analytics
Capture Triage in hospitals, clinics, hubs • Relevant Vital signs • Symptoms • Contact with animals • Recent Travel
• Demographics • Chronic disease history
Possible Case/ under
investigation
Symptoms suggestive
Visualize Connecting the dots and visual management
• Radiology • Lab tests PCR : CBC,
LDH, AST etc
Probable Case Positive radiology- Blood tests
Confirmed PCR positive
Analyze: • Pathway compliance • Radiology response time • Lab turn-around –time TAT
• Possible/Probable/ Confirmed rates
• False positive/negative test rates
• Demographic trends
Fast-track demonstration of tools tailored for MERS:
Fully operational system (contingent on data access, MoH resources committed, scale, cloud space, etc. )
• Real- time data and surveillance • Highly Flexible system that can
be used in the future for many disease scenarios whether infectious or other
4. Elements: Clinical Effectiveness
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What is it? Thoughts?
The measure of the extent to which a clinical intervention worked – in light of the clinical intervention and the extent to which it represents value for money, based on international guidelines and protocols for different diseases. It involves health service research and scientific reviews to improve health service delivery through periodic reviews to reflect insights from such analyses It is important for hospitals to pay attention to clinical effectiveness because hospitals and healthcare practitioners all over the world are increasingly being asked to justify their clinical practice or risk law suits with varying severity of consequences.
5. Elements: Clinical Audit
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What is it? Thoughts?
A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change
• A way of improving care
• Use a multi-disciplinary approach,
• Logical and systematic
• Introspective
• Patient focused
Clinical Quality Improvement (CQI)
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Clinical Effectiveness
Clinical Audit + Evidence Based
Medicine Clinical Quality Improvement +
CQI has evolved to tackle the “evidence into practice gap”: EBM and CQI go hand–in-hand 1
Evidence Based Medicine (EBM) • Coined by Gordon Guyatt in 1992 for
JAMA • Described the bedside use of research
to improve patient care • Adopted in a variety of ways including
the development of clinical practice guidelines
Clinical Quality Improvement (CQI) • Emerged in the 1980’s; focus on
recurrent problems within systems • Adapted to healthcare from W. Edward
Deming’s work in industrial Japan • Led to the establishment of the
Institute of Healthcare Improvement (IHI) and the PDSA model
‘Doing the right thing’
EBM + CQI = ‘Doing the right things right’
‘Doing things right’
Source: 1 Glasziou, P; Ogrinc, G; Goodman, S. Can evidence-based medicine and clinical quality improvement learn from each other? BMJ Qual Saf 2011;20 (Suppl 1):i13-i17)
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One of the main drivers for CQI is the problem of clinical variation
Clinical Variation describes differences in care that is delivered to
patients with the same condition
“If all variation were bad, it would be easy to stop it . What is difficult , is reducing the bad variation while keeping the good.”1
– Dr Al Mulley, Dartmouth Institute
Some clinical variation is appropriate…
“good” or “warranted”
Care is patient-centred
• Clinical differences • Personal differences
The majority of clinical variation is inappropriate…
“bad” or “unwarranted”
Care is not evidence-based • Omission • Commission
SOURCE: 1Mulley, AJ. Improving Productivity in the NHS. BMJ 2010. 341:c3965
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Our understanding of clinical variation is growing
DARTMOUTH ATLAS1
First published 1999 Examples of variation in the US: • Diabetics in Chicago – 50% less
likely to receive lipid monitoring
• Medicare pays 2 x more per patient in Miami than in Albuquerque with no difference in life expectancy
NHS ATLAS OF VARIATION2
First published Nov 2010 Examples of variation in England: • 35 fold variation in diabetics
receiving established 9 key care processes
• 4 fold variation among stroke patients who spend <90% of stay on stroke unit
SOURCE: 1http://www.dartmouthatlas.org; 2http://www.rightcare.nhs.uk/index-php/nhs-atlas/
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The case for Clinical Quality Improvement
Source: 1McGlynn E. The Quality of Healthcare delivered to Adults in the US. NEJM. 2003: 348; 2635-2645; 2Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001; 3Crump H. ‘Variation shows NHS community services ripe for efficiencies’. Health Service Journal, 13 August 2009; 4Appleby J, Ham C, Imenson C, M Jennings. Improving NHS Productivity, more with the same, not more of the same. The Kings Fund. July 2010.
Evidence–based medicine is essential to high quality and cost effective care Inconsistent delivery of best practice, results in up to 45% of patients failing
to receive the recommended, evidence-based package of care1
Untended variation has a significant impact on quality and cost - $12 billion in avoidable medical expenses and deaths in the US2 and an estimated savings of £4.5 billion achievable among hospitals in England3
Lower cost base while improving quality … “Many of the most significant opportunities to improve productivity will come from clinical decision-making & reducing variations in
clinical practice.” ~ The Kings Fund4 ~
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Elements: Clinical Audit
Part of Clinical Quality Improvement
• Could include structure, processes and outcomes.
• Measures against standards and/or
explicit criteria
• Changes are implemented at an individual,
team or service level.
• A re-audit used to reconfirm
• Topics should reflect priorities or areas of
concern
• Is a multi-disciplinary activity
• Looks at the patient journey
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Select a topic for the audit
Define standards
Measure performance
against standards
Review standards in the light of
performance
Adapt the health service
delivery system
Start
The formal clinical audit process
While the audit looks like it is an inspection, the focus should be on improving the process
Identifying the process Who should say what the process should be ?
Lobby Time Time to Park Car
Registration
Walk to Procedure Area
Procedure Time Time to drive to facility
Hospital’s View of “Registration”
Patient’s View of “Registration”
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Define Measure Analyze Improve Control
Lean
Six Sigma
Plan Do Check Act
PDCA
Preparation
& Training
Assessment
& VSM Kaizen Sustainability
Post-Kaizen Assessment
Process Improvement
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Continuous Quality Improvement
42 Time
Qu
alit
y
improvement security
CQI Cycle: PDCA
Do
Check Act
Plan
Measuring is key….but what is a Quality Indicator?
An Indicator is a Quantitative Measurement that is Rate Base (Numerator and Denominator) rated over time for comparison to standard
benchmarks and used for quality improvement projects
Face Validity
Precision
Minimum Bias
Application
Foster Quality
Improvement
Construct Validity
Indicators must be key to organizational success
5. Element: Research and development
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R&D is not something to be done just at a personal level but at an institutional level… .this means it needs institutional governance
Two major governance structures are needed: Scientific committee which decides on whether a research proposal is aligned with the healthcare institution's research priorities. ( Funding priorities, availability of resources, and whether the proposal has sound scientific foundations) Internal Review Board (IRB) which approves whether the research
proposal/methodology conforms with the standard of ethics for medical research.
Facilitate Research Partnership / Monitoring and Evaluation
Establishing Research Liaison Office that will :
Saudi
Center for
Evidence
Based Health Care
Validate
EBHC
Directorate
for Research
and Studies
Department
of Statistics
Take into account Research Priorities in shortlisting CPGs adaptation
Take into account recommendations for increased research in areas of weak evidence in the CPG adaptation process
Use data to drive research around compliance and implementation correlating it to population health monitoring through tools such as Corvix
6. Element: Information Management
The Governance of collection, management and use of patient
records and information.
Examples of systems that fall within this jurisdiction are:
1- Paper or electronic health records
2- Radiology management systems
3- Lab management systems
4- Advanced Analytics
Safeguarding patient privacy and minimizing unnecessary access are key
What Excellence in Clinical Quality Improvement looks like….and how they did it
“being not bad does not mean you are good.”
~ Dr D Lappe,
Head of Cardiovascular Clinical Programme, Intermountain Healthcare
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The Intermountain Healthcare Story
Intermountain Healthcare: A pioneer and global exemplar of Clinical Quality Improvement
Facilities 23 hospitals 185 outpatient
clinics US (Idaho and Utah)
Employees 4,500 total
physicians 33,000 total
employees Information Systems
1,025 FTEs Approximately $200
million budget pa
US Integrated Delivery System
Intermountain is the only organisation in the US to have been ranked as the No. 1 Integrated
Delivery System 5 times - based on efficiency, communication, cost and quality of care
Source: 1James, B, Savitz L. How Intermountain trimmed healthcare costs through robust quality improvement efforts. 2011: no 6; 1185-1191
http://www.youtube.com/watch?v=mPIUE
Y2GD5U 48
Sustaining the delivery of clinical quality across a large system
Clinical Programs
• Focus on what’s important – variation, activity, cost
• Agree standardized ‘best practice’ pathways – “Shared baselines”
• Implement evidence-based practice standards and monitor clinical
performance against these standards
• Establish a common model for change
• Build a quality improvement culture around data-driven decision
making and teamwork
• Focus on agreed clinical programs…early adopter successes
• Capture, retrieve, analyze, report high quality pathway data
• Ensure data is trustworthy & timely…value add to clinicians
• Invest in electronic patient records and tools to pull near real time
data into clinical workflows
Organisation & Culture
Data & Technology
The three core elements of Intermountain’s CQI model
Intermountain’s journey began with rigorous analysis to prioritise improvement opportunities
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Of the 1,400 clinical conditions managed at Intermountain, 104 of these account for
93% of the care it delivers
1,260 104
Co
mm
on
clin
ica
l co
nd
itio
ns
rep
rese
nt 8
% o
f
the
to
tal
Most frequent clinical conditions
Less frequent clinical conditions
11% attributed to Labour & Delivery
10% attributed to IHD*
Profile of Intermountain’s patient population (no. of different clinical conditions presenting to Intermountain hospitals; n=1,400)
*IHD-Ischaemic Heart Disease
Total number of clinical conditions presenting to Intermountain hospitals
Clinical & Operational Staff Clinical Expert Group
Focused analysis led to the development of over 70 ‘best practice’ clinical protocols (comprising 90% of Intermountain’s casemix)
Clinical Protocol Development Model1
• Review scientific literature
• Review Intermountain’s clinical
data repository Re
vie
w
• Ensure protocol is workable
through rigorous testing and
clinical engagement
• Agree with clinical staff, ‘shared
baselines‘ around best practice
• Define each data element (e.g.
symptom, physical obs, labs etc.) • Define expected timing for patient
Dx, Rx, recovery/follow-up
• Design clinical protocols and
embed into IT system according to
clinical workflow
De
fin
e &
De
sig
n
With collectively agreed, best practice ‘shared baselines’, about 80% of all care delivered
is evidence-based, compared with a US industry average of 55% 2
Test
M
on
ito
r &
Su
sta
in Both teams are permanent & jointly:
• Track scientific literature and
Intermountain’s own data
• Monitor compliance to agreed protocols, with near real time
documentation of variance
• Make minor adjustments to
protocols on a monthly basis
• Make major revisions every 2 yrs
1
2
3
4
Source: 1 Bohmer, R. Fixing Healthcare on the frontline. Fixing healthcare from the inside & out. 2011. Harvard Business School Publishing Corp. 2McGlynn E. The Quality of Healthcare delivered to Adults in the US. NEJM. 2003;: 348; 2635-2645. http://www.nejm.org/doi/pdf/10.1056/NEJMsa022615
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Disrupting ‘traditional’ care delivery structures in favour of ‘clinical programmes’ was essential for success
Clinical Integration Matrix Intermountain’s clinical integration model includes 9 clinical programmes (the ‘verticals’)
centred around its 70+ agreed, localised, evidence based clinical protocols. Each programme is physician led and is accountable for ensuring successful delivery of the specific clinical protocols
across the continuum of care (hospital to community). Various supporting ‘horizontal’ functions, work intimately with
each programme to assist teams in providing consistent delivery of care.
Examples of
‘horizontal’ supporting functions
Intermountain’s existing clinical programmes: the ‘verticals’
Although the model is flexible, Intermountain data shows that clinical protocols, based on ‘shared baselines’ and supported by the clinical programmes, leads to minimal
variation, with only 5 to 15% warranted variance occurring across its system.
Source: James, B ; Lazar, J. Sustaining and extending clinical improvements. (Chapter 7) A framework for the continual improvement of healthcare: building and applying professional and improvement knowledge to test changes in daily work. Joint Commission Journal of Quality Improvement 1993; 19(10) 424:424-52 )
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Embedding a culture of CQI, with core knowledge and skills among clinical staff is key to sustainability
Continual Improvement
• Change the clinical and
administrative culture - impacting a
sufficient number of staff to embed
the change system wide ( “square
root of n”)
• Build on the foundation of the
‘healing professions’ and take clinical
staff on the improvement journey
• Demonstrate benefits to the
organisation of releasing clinical staff
to attend training
3 key aims for CQI training
Professional
knowledge Subject matter
expertise Discipline Values
Improvement
knowledge • Processes /
systems • Variation Mgmt • Change Mgmt
CQI training for Clinical Staff
Source: A framework for the continual improvement of healthcare: building and applying professional and improvement knowledge to test changes in daily work. Joint Commission Journal of Quality Improvement 1993; 19(10) 424:424-52 (Ocr)
Intermountain has trained over 3000 of its clinical staff in clinical quality improvement methods to successfully support change
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Intermountain is regarded as one of the most advanced users of IT and data to drive sustainable continuous quality improvement while lowering cost
Results… Elective induction <39 wks was reduced from
30% to less than 3%
What the guidelines state… Elective induction should not be preformed <39 wks
1.12%
0.45%0.21%
37th Week 38th Week 39th Week
Sustained
Percentage on Ventilator
Leveraging data and technology to transform patient care and reduce variation: A case study
What the data showed… . Increased risk of ventilation-associated
complication with elective induction <39 wks
$1.5M recurring savings + quality improvements
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CQI success highlighted by measuring performance against ‘best practice’
Core Measures • US clinical quality performance
measures • Initially part of Joint
Commission accreditation; adopted by Medicare/Medicaid
• Used to benchmark hospital
clinical performance and spur improvement
• Focused on high volume, high variation areas: MI, CHF, Pneumonia, Surgical care
SOURCE: 1 Kfoury A, Incremental survival benefit with adherence to standardized heart failure core measures: A performance evaluation study of 2958 patients. Journal of Cardiac Failure 2008. Vol 14 (7); 95-102.
Intermountain’s 12 month mortality results shows improved outcomes when heart failure patients get all four recommended interventions or the “full package of evidence-based care”. This includes: 1) Discharge instructions; 2) Evaluation of LV function; 3) ACE or ARB for LVSD; 4) Smoking cessation advice.1
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Further examples of Intermountain’s system wide clinical quality improvement successes
• Perioperative cardiovascular surgery glucose control led to significantly reduced morbidity, mortality and costs
• Discharge med program for coronary heart disease and heart failure patients significantly reduced readmissions, mortality, and costs
• Reduced blood transfusions by 50% in open heart surgery patients, making considerable savings and improving predicted outcomes
• Comprehensive patient education combined with “Partners in Healing” programme (involving family in the care and discharge process of cardiovascular patients) has reduced readmissions and complications
• Integrated imaging network allows rapid reading of imaging studies and access throughout their system to reduce repetition of tests and reducing time to diagnosis and treatment
Intermountain can point to more than 100 successful clinical improvement initiatives introduced since 1995
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Summary of key CQI lessons learned
1) Most variation is due to process failure, not individual failure – improve the processes
so that they support staff to “do the right thing
2) Focus improvement efforts on high-volume, high cost, high variance clinical areas
3) Understand the evidence base and analyse the data against this
4) Agree ‘shared baselines’ and ‘localise’ best practice
5) Identify and target barriers to optimal care
6) Integrate clinical and operational staff to support quality care
7) Leverage IT to capture, analyse, share and report essential data to frontline clinicians
in near real time….not 6 months later when clinical decisions have already been made.
8) Apply knowledge generated by day-to-day care to build ongoing, continuous learning
Fundamental CQI Lessons
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Why does Change Matter?
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Managing Change in Healthcare
GE’s Change Research
100% of all changes evaluated as “Successful” had a good technical solution or approach
Over 98% of all changes evaluated as “Unsuccessful”
also had a good technical solution or approach
____________________________________________
What is the differentiating factor between success and failure?
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The Change Equation
Quality
Q x A = E 3
Acceptance Accountability
Alignment
Effective Results
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Effective Leadership Practices
Change initiative focused on
customer needs (target)
Speed = Integrating Problem Solving with Engagement
Implementing change Q x A3 = E
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“We cannot solve problems with the same thinking we used
when we created them."
Albert Einstein
GE Internal - For internal distribution only.
Root Cause Analysis
Symptoms
Root Causes
ROPE OF SCOPE
FUNNEL OF FOCUS
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Change Paradigm
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Creating a Shared Need
… Burning platform
… Sense of Urgency
… Challenge the status quo
Threat vs. Opportunity Matrix
Three “D’s” Matrix
– Data
– Demonstration
– Demand
Tools:
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Creating a Shared Need
Uses: Building the case for change is one of the first and most important tasks of the team. This simple tool helps the team discover how to frame the need for change more broadly and perhaps break some old habits about change only as it applies to a short-term threat.
Threat vs. Opportunity Matrix
Tool: Threat vs. Opportunity Matrix – Best Practice organizations know how to frame the need for change as more than a short-term threat. They work to find ways to frame the need as a threat and opportunity over both the short and long-term. By doing so, they begin to get the attention of key stakeholders in a fashion that ensures their involvement beyond what can be gained from a short-term sense of urgency.
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Three D's matrix
Creating a Shared Need
Data/Diagnosis
-Internal sources
-External sources
What data do we have or need?
Demonstrate
-Leading by example
-Best Practices
-Visiting other organizations
Show Me! Where is it working/not working?
Demand
-Dynamic Leadership
-High standards
-Regulatory
Who or what is driving it?
Approaches Ideas Actions
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99.99966% Good (6 Sigma)
Unsafe drinking water for almost 15 minutes each day
52 incorrect site surgeries every 5000 surgeries
Two short or long landings at a
major airport each day
10,000 wrong drug prescriptions per 1 million filled each year
Unsafe drinking water for one
minute every seven months
1.7 incorrect site surgeries every 500,000 surgeries
One short or long landing every five years at a major airport
3.4 wrong prescriptions per 1 million filled each year
99% Good (3.8 Sigma)
Using Six Sigma performance
Creating a Shared Need
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Mobilizing Commitment
Why bother?
Need sufficient support and involvement from key stakeholders
Critical mass must be won over
Key difference between success and failure
What are we after?
Coalition of committed supporters
Identification of potential resistance
Conversion of key influencers
Mobilizing Commitment positions the team for downstream interventions.
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Two Sides of the Coin
Intentional (those who make the decisions)
THEM
• envisioned by leaders
• is a conscious decision
• is anticipated
• is gradual
• is incremental
• is paced
• solves problems
• provides new opportunities
Imposed (those required to implement the decisions)
US
• is a decision without choice
• is unexpected
• is dramatic (lightening bolt)
• is rapid (out of control)
• creates problems
• disrupts routines
Adapted From: Managing at the Speed of Change by Daryl R. Conner
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…so quality improvement in Healthcare is about CHANGE
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