Organizational Leadership - Hamad Medical Corporation Home · 2019-03-26 · Defining a portfolio...
Transcript of Organizational Leadership - Hamad Medical Corporation Home · 2019-03-26 · Defining a portfolio...
Organizational Leadership 7th Annual Middle East Forum on Quality and Safety in Healthcare
March 22, 2018 Doha, Qatar
Derek Feeley President and CEO, IHI Maureen Bisognano President Emerita and Senior Fellow, IHI
ME Forum 2019 Orientation
As part of our extensive program and with CPD hours awarded based
on actual time spent learning, credit hours are offered based on
attendance per session, requiring delegates to attend a minimum of
80% of a session to qualify for the allocated CPD hours.
•Less than 80% attendance per session = 0 CPD hours
•80% or higher attendance per session = full allotted CPD
hours
Total CPD hours for the forum are awarded based on the sum of CPD
hours earned from all individual sessions.
Conflict of Interest
The speaker(s) or presenter(s) in this session has/have no conflict of
interest or disclosure in relation to this presentation.
Our Leadership Challenges
• Building a leadership culture to achieve the results we seek
• Aging, and the increasing burden of chronic disease
• New 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
• Designing a learning system to decrease variation
Qatar National Health Strategy
Principles • Action and empowerment
– “Come together for the good of our country, and the health of our people, our families, and our patients”
• Teamwork and collaboration
• Patient-centered care
• Accountability and patient safety
• Leadership
• Intelligence
• Empathy
4
Some New Ways to Live the Principles
and Lead to Improved Care
• New leadership ideas
• Innovative models of care
• Accelerating the rate of improvement
5
Concepts Operational Definition
Theory The science of improvement includes system thinking, understanding variation, psychology of change, and the theory of knowledge that are applied to improve the performance of processes, organizations, and communities.
Culture, Behaviors, and Relationships
Series of principles and behaviors based on improvement science and applied to all work including: constancy of purpose, relentless focus on continual improvement, recognizing the need to distinguish random from attributable variation and the difference in how you act, learning through experimentation, inquiry, curiosity, Socratic mentoring, comfort with failure, etc.
Organizational System
A system is an interdependent group of items, people or processes working together toward a common purpose. Processes that are designed to produce quality for the customer and reduce variation and waste. Understanding the system is supported by a vector of measures.
Quality Activities
Include different phases of delivering quality including: planning, innovation, improvement, implementation, and control. Limited quality assurance may be required to meet external regulator requirements.
Leadership Framework
A framework for leadership to focus organizational attention and activity to continually operate and to improve on strategic priorities. This includes establishing the foundation and supporting building will, generating ideas, and supporting execution.
Strategic Execution
Defining a portfolio of strategic priorities with chartered projects that include measurable aims, “evidenced-based” change ideas, and a measurement strategy. Execution is supported with resources, protected time, and integration into daily work.
Content Models, frameworks, and/or change packages developed by subject matter experts, innovation cycles, best practice, or research that provide content and ideas for testing and improvement. Examples: Patient Safety Framework, Joy in Work Framework.
Improvement Approach
The Model for Improvement is an improvement approach to charter aims, measures, and changes for an improvement project and uses the PDSA cycle and time series data to test and improve.
Tools & Methods
The proper application of this science requires integration of a set of improvement methods and tools with knowledge of subject matter to develop, test, implement, and spread changes. Tools include check sheets, cause & effect, process mapping, histograms, pareto, etc.
Create Energy
2 Differentiators
Strengths Leadership Characteristics
Trust Compassion
Stability Hope
11
5 Sources of Meaning
Society
Company &
shareholders
Customers
Team
experience
Personal
success
____________ %
Improving society
Building the community
Stewarding resources ____________ %
____________ %
____________ %
____________ %
Leading the industry
Increasing share price
Paying dividends
Making it easy for the customer
Providing superior service
Making better quality products
Nurturing high-performing teams
Bolstering sense of belonging
Fostering a caring meritocracy
Achieving personal development
Receiving recognition in my field
Earning a big bonus/stock options
Becoming Multilingual to Build the Will for
Change
13
5 Sources of Meaning
Society
Company &
shareholders
Customers
Team
experience
Personal
success
____________ %
____________ %
____________ %
____________ %
____________ %
Create Trust
Trust and Camaraderie
Adapted from Lencioni
15
Critical Components for Ensuring a Joyful, Engaged Workforce Interlocking responsibilities at all levels
Wellness & Resilience
Physical & Psychological
Safety
Daily Improvement
Meaning & Purpose
Recognition & Rewards
Choice & Autonomy
Participative Management
Happy
Healthy
Productive
People
Camaraderie
& Teamwork
Real Time
Measurement
Physical & Psychological Safety: Equitable environment,
free from harm, Just Culture that is safe and
respectful, support for the 2nd Victim
Meaning & Purpose Daily work is connected
to what called individuals to practice, line of site to
mission/goals of the organization, constancy
of purpose
Autonomy & Choice: Environment supports choice and flexibility in
daily lives and work, thoughtful EHR implementation
Recognition & Rewards:
Leaders understand daily work, recognizing what
team members are doing, and celebrating
outcomes
Participative Management:
Co-production of Joy, leaders create space to hear, listen, and involve before acting. Clear communication and
consensus building as a part of decision making
Real Time Measurement: Contributing to regular feedback
systems, radical candor in assessments
Wellness & Resilience: Health and wellness self-
care, cultivating resilience and stress management, role
modeling values, system appreciation for whole
person and family, understanding and
appreciation for work life balance, mental health
(depression and anxiety) support
Daily Improvement: Employing knowledge of
improvement science and critical eye to
recognize opportunities to improve, regular,
proactive learning from defects and successes
Camaraderie & Teamwork:
Commensality, social cohesion, productive
teams, shared understanding , trusting
relationships
17
Who’s on your boat and do they have the skill and the will needed?
Not aware; left behind; will not take a leap of faith
Opposed to change; strong believer in cur- rent way of doing things and willing to fight for it
Interested in the program but lack skills/ knowledge to contribute fully
Fully supportive of the change program
Castaways (20%) Pirates (10%)
Crew (50%) Captains (20%)
• Take a moment to consider
where your team is on the
boat and who is…
• High skill, high will?
• High skill, low will?
• Low skill, high will?
• Low skill, low will?
What steps can you take to
address each of these folks?
SOURCE: McKinsey & Company, Organization Practice
Leadership to Improve
• What we believe
• What we say
• What we see
• What we do
18
What We Believe
• The leader’s role focuses on creating the energy
for change
• Working with humility to inspire a culture of
safety and trust
• Committing to the best we know for all
• Pushing the limits for a strong future
19
A Healthcare Example
• Jonathan Goble, CEO IU Health North
– “A positive culture is intentional, and evolves by the
commitment, empathy, and creativity of all ..to create
passionate care and impeccable service.”
– Mission: To improve the health of communities, to
support the educational commitments of IU, to nurture
individual spirit and to celebrate the experiences of
life.”
20
IU North’s Vision
• Excellence in care
• A peaceful environment
• Extraordinary service
• The effective blending of technology, compassion and spirit
• A seamless continuum of care, blending community-based
and academic services to grow knowledge and expertise
• A team approach in which the patient and family are the
ultimate priority
21
IU Health North Core Maxims
• Show kindness-Before I do anything, I must first
demonstrate genuine kindness. People don’t
care how much I know unless they know how
much I care.
• Connect fully-I must listen, make eye contact,
and seek to understand my patient’s needs. I will
make every person uniquely appreciated.
22
IU Health North Core Maxims
• Take ownership-I choose to be responsible for
my actions, attitudes and decisions.
• Create joy-I have the power to be positive and
lift the spirits of those around me.
• Do more-I will look for ways to surprise my
patients by doing more than they expect.
23
What We Say
• Build and use your influence
• Bob Waller’s 8 x 8
• Stories of impact
• Listening with curiosity
• “Above the line”
“Key ideas drive cultural change. For every
important message, I deliver it 8 ways, 8
times.”
- Dr. Robert Waller, CEO Emeritus, Mayo Clinic
To Be Happy, Be Curious
• James Ryan’s Five Questions:
1. “Wait, what?” – understanding
2. “I wonder…” – curiosity
3. “Couldn’t we at least…” – mobilize
4. “How can I help?” – asking is key
5. “What truly matters?”
Source: Mineo, Liz. “Want to be Happy? Be curious.” Harvard Gazette. 14 Apr. 2017.
27
28
Humility
New Quality (and Safety) Paradigm
Old way New way
Quality is about compliance. Quality is about continuous, systematic improvement.
Quality is a function of governance. Quality is a shared responsibility.
Data is for assessment. Data is for rapid adjustment.
Power is concentrated (in the hands of the checkers).
Power is distributed to patients and staff at the point of care.
Leadership creates standards.
Leadership creates culture.
Listen to Understand – Not to Respond
“Wide lugs and a short tongue
is best”
Scottish Proverb
Ask and Listen: Heroism is Out, Humility is In!
Schein on Culture
• Culture is a result of what an organization has learned from dealing with problems and organizing itself internally
• Your culture always helps and hinders problem solving
• Culture is a group phenomenon • Don’t focus on culture because it can be a bottomless
pit. Instead, get groups involved in solving problems
What We See
• “Real” rounds
• Journey of a patient
through a time of care
• Spaghetti diagrams
• Commensality
Source: Ron Bialek, Grace L. Duffy, and John W. Moran, The Public Health Quality Improvement Handbook (Milwaukee, WI: ASQ Quality Press, 2009), page 220.
Cede Power
“For every complex problem there is an answer that is clear, simple, and wrong."
H. L. Mencken
NEW PUBLIC MANAGEMENT Targets, sanctions, inspections
QUALITY IMPROVEMENT
MOBILISING SOCIAL ACTION O
utco
me
s
Time
Getting to the Third Curve
Sharing power
Keeping power
Ceding power
PERFORMANCE MANAGEMENT
QUALITY IMPROVEMENT
CO-PRODUCING
Create Ability
AGENCY The ability of an individual or group
to choose to act with purpose
Power
The ability to
act with purpose
Courage
The emotional resources
to choose to act
Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology
Psychology of Change
IHI Psychology of Change Framework
Unleash Intrinsic Motivation
Tapping into sources of intrinsic motivation galvanizes people’s individual and
collective commitment to act.
Co-Design People-Driven Change
Those most affected by change have the greatest interest in designing it in ways that are meaningful and workable to them.
Co-Produce in Authentic Relationship
Change is co-produced when people inquire, listen, see, and commit to one another.
Distribute Power
People can contribute their unique assets to
bring about change when power is shared.
Adapt in Action
Acting can be a motivational experience for people to learn and iterate to be effective.
z z
Activate
People’s
Agency
Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology
Joy in Learning
What do these have in common?
NASA Challenger BP Gulf Spill Mid Staffs NHS
The Cycle of Fear 45
Increase Fear
Kill the Messenger
Filter the Information
Micromanage
Personal Resilience
Networks
From Ideas to Action
• Flow across the system
• Waste and cost
• Safe care
• Joy in work
• Patient-centered redesign
53
Achieving Hospital-Wide Patient Flow
http://www.ihi.org/communities/blogs/why-hospital-flow-is-key-to-patient-safety
54
Does every hospital admission need a
root cause analysis? • “No fault hospitalization”
• Preventable with traditional medical care
• Preventable with attention and intervention in social determinants
• Medical error
• Flow problems
• Staffing challenges
• Communication and handovers
55
Source: Mark Depman, NJEM Catalyst, October 18, 2017
A New Way
• Engineered and designed flow
• Upstreamism
• Outplacing
• Partnering in care
56
16-Bed MICU:
“We need more beds!”
57
Source: Bela Patel, MD and Khalid Almoosa, MD
“We have plenty of ICU beds!”
• VAP/ BSI rates Zero - $54,000/$ 35,000
• EC- ICU 53% to 75% in 4 hours • Hospital LOS decreased 1.5 days $$
• Floor codes decreased 50%
• End of Life –ICU stay –decreased 3.3 days
• Mortality decreased by 13%, CMI up 15%,
• Occupancy decreased from 94.5% to 85.5%
• Monthly admissions: from 89.4 to 104.6
• $5.1 Million saved
58
Source: Bela Patel, MD and Khalid Almoosa, MD
James M. Anderson Center
for Health Systems Excellence
Daily Critical Flow Failures
0123456789
7/1
6/2
008
10/1
4/2
…1/1
2/2
009
4/1
2/2
009
7/1
1/2
009
10/9
/20
09
1/7
/201
04/7
/201
07/6
/201
010/4
/20
10
1/2
/201
14/2
/201
17/1
/201
19/2
9/2
011
12/2
8/2
…3/2
7/2
012
6/2
5/2
012
9/2
3/2
012
12/2
2/2
…3/2
2/2
013
6/2
0/2
013
9/1
8/2
013
12/1
7/2
…3/1
7/2
014
6/1
5/2
014
9/1
3/2
014
12/1
2/2
…3/1
2/2
015
6/1
0/2
015
9/8
/201
512/7
/20
15
3/6
/201
66/4
/201
69/2
/201
612/1
/20
16
3/1
/201
75/3
0/2
017
8/2
8/2
017
# o
f P
ati
en
ts w
ith
a N
ew
F
ail
ure
Delayed or Canceled Surgery Due to Bed
Capacity
0123456789
7/1
6/2
008
10/1
4/2
…1/1
2/2
009
4/1
2/2
009
7/1
1/2
009
10/9
/20
09
1/7
/201
04/7
/201
07/6
/201
010/4
/20
10
1/2
/201
14/2
/201
17/1
/201
19/2
9/2
011
12/2
8/2
…3/2
7/2
012
6/2
5/2
012
9/2
3/2
012
12/2
2/2
…3/2
2/2
013
6/2
0/2
013
9/1
8/2
013
12/1
7/2
…3/1
7/2
014
6/1
5/2
014
9/1
3/2
014
12/1
2/2
…3/1
2/2
015
6/1
0/2
015
9/8
/201
512/7
/20
15
3/6
/201
66/4
/201
69/2
/201
612/1
/20
16
3/1
/201
75/3
0/2
017
8/2
8/2
017# o
f P
ati
en
ts w
ith
a N
ew
F
ail
ure
PICU Bed Not Available for Urgent Use
0123456789
7/1
6/2
…10/1
4/…
1/1
2/2
…4/1
2/2
…7/1
1/2
…10/9
/2…
1/7
/201
04/7
/201
07/6
/201
010/4
/2…
1/2
/201
14/2
/201
17/1
/201
19/2
9/2
…12/2
8/…
3/2
7/2
…6/2
5/2
…9/2
3/2
…12/2
2/…
3/2
2/2
…6/2
0/2
…9/1
8/2
…12/1
7/…
3/1
7/2
…6/1
5/2
…9/1
3/2
…12/1
2/…
3/1
2/2
…6/1
0/2
…9/8
/201
512/7
/2…
3/6
/201
66/4
/201
69/2
/201
612/1
/2…
3/1
/201
75/3
0/2
…8/2
8/2
…
# o
f P
ati
en
ts w
ith
a N
ew
F
ail
ure
Patients who Utilize an ICU bed b/c an Appropriate
Bed is Not Available
0
2
4
6
8
10
12
7/1
6/2
008
10/1
4/2
…1/1
2/2
009
4/1
2/2
009
7/1
1/2
009
10/9
/20
09
1/7
/201
04/7
/201
07/6
/201
010/4
/20
10
1/2
/201
14/2
/201
17/1
/201
19/2
9/2
011
12/2
8/2
…3/2
7/2
012
6/2
5/2
012
9/2
3/2
012
12/2
2/2
…3/2
2/2
013
6/2
0/2
013
9/1
8/2
013
12/1
7/2
…3/1
7/2
014
6/1
5/2
014
9/1
3/2
014
12/1
2/2
…3/1
2/2
015
6/1
0/2
015
9/8
/201
512/7
/20
15
3/6
/201
66/4
/201
69/2
/201
612/1
/20
16
3/1
/201
75/3
0/2
017
8/2
8/2
017# o
f P
ati
en
ts w
ith
a N
ew
F
ail
ure
Psychiatry Patients Placed Outside of their
Primary Unit
James M. Anderson Center
for Health Systems Excellence
System Wide Patient Flow Delays
Confidential proprietary information of Cincinnati Children’s Hospital Medical Center. Do not distribute.
Provider Conferences
Outpatient Consultations
Inpatient Consultations
Diagnostic Testing
Remote Patient Monitoring
Common to Complex- ECHO
Model
Additional Virtual Patient Care
Telehealth at Cincinnati Children’s
Patient Flow| Operational Control Center
Patient Flow| Accelerator Program
Patient Flow
Care
Units
Registration
Pre Admission
MDA
Support
Medical staff
Surgery Center
ER
Surgical Scheduling
Medical Practice
Readmissions
4.10
3.87 3.96 3.86 3.81
3.75 3.64
3.51 3.40 3.28
34 20 36 44 54
74 97 117
147
Decrease length of stay and the virtual beds gain
Length of stay Virtual gain capacity (beds)
The reduction in LOS provided a capacity gain equivalent to 147 virtual beds
Flow
• What innovations have you implemented? What works and what doesn’t?
• Do you need new roles?
• What delays and complications can you improve?
• What leadership driver do you most need to enhance?
64
Eliminate Waste and Managing Value
• “Seeing” waste
• Adding value
• Equipping staff
65
Reducing Harm, Waste and Variation
Reduce Waste
“50%of all resource expenditure in hospitals is quality-associated waste”
- recovering from preventable foul-ups
- building unused or unusable products
- providing unnecessary treatment
- simple inefficiency
Brent James and Lucy Savitz – Intermountain Healthcare
“See” the Waste 68
Trillion Dollar Checkbook
1. Reduce harm & safety events
2. Reduce non-value added operational workplace waste
3. Reduce non-value added clinical workplace waste
4. Solicit staff and clinician ideas
5. Involve patients in identifying what matters most
6. Redesign care to achieve Triple Aim
69
70
BUILDING ON THE WEDGES OF WASTE (Hackbarth/Berwick): REDUCING THE BAG OF $ - A Starting Checkbook for Big & Smaller US Healthcare Waste (starting list - Helen Macfie & Jim Leo) - DRAFT
Primary Drivers / Waste Opportunity
BOLD Goal Relative Ease Priority
Savings Goes To: Average Avoidable Cost per Instance Avoidable Volume, USA Lower Bound Total $$ (CxD) Billions
Upper Bound Total $$ (C x D) Billions
Definitions/Notes Overall Approach/Ideas Barriers and Obstacles to Plan For
P1: Reduce Harm & Safety Events
Infections - reduce hospital acquired
Reduce Infections of 5 HAIs by 40%. Note: Focus on CLABSI, VAP, SSI, CAUTI, CDI.
"EASY" PROVIDER: $5.5 billion SSI = $20,786/case, CLABSI = $45,814/case, CAUTI = $896/case, VAP = $40,144, CDI = $11285/case
65% of CLABSI cases, 55% of VAP cases, 26% of SSI cases, 50% CDI cases, and 70% of CAUTI cases
$4.60 $6.50 IHI/Published cost savings/infection type Toolkits (existing) IHI Campaign, renewed Local systems/design
Renewed attention
Sepsis Reduce Cost by 25% Note: not published but MemorialCare has reduced direct variable cost from $28K/case to $22K/case (21%) for severe sepsis and septic shock cases, while reducing mortality by 55% for patients who are not DNR within first 24 hours of hospital care.
"EASY" PROVIDER
Sepsis attributable hopsital costs at index hospitalization and 90 days post discharge: $32,900/pt surgical, $5,800/pt nonsurgical.
20-25% reduction in sepsis cost/case Note: we have not yet quantified impact of reducing actual cases coming in from the community
$4.50 $5.60 Surgical v non-surgical patients with sepsis
Toolkits (surviving sepsis) IHI "Campaign", renewed Local systems/design Community education - earlier recognition
Renewed attention; Community Partnerships
Improve Medication Reconciliation and Reducing Readmission
Focus: Improve clinical Medication Reconciliation across Continuum of Care to "90"%
MEDIUM PAYOR Between $10,100 and $14,200 in payments per readmission
27% reduction in all-cause readmission rate after implementation of medication reconciliation program
$14.50 $20.30 Improve "good" reconciliation within 48-72 hours of transfer to alternate level of care (focus on home first)
Uniform criteria needed Standardized approach needed
Provider resources Systems/documentation (EHR records)
Opioid Use Reduction Reduce Dispensed Opioids by "20-40"% Ex: Reduce opioid Rx for opiate-naïve patients at discharge or new outpatient Rx to <7 day supply (if they need it at all. Note: Does not include reduced cost from avoided opioid dependence with associated chronic care costs (excluding overdose).
MEDIUM PROVIDER $4,006 per opioid poisoning event (includes ED, OP, ambulatory, and nalaxone costs) -------------------------------------$15,935 all-cause medical cost differential per patient between 1 year before initial opioid precription and 1 year post initial precription (among chronic opioid users)
22% reduction in morphine milligram equivalents (MME) per person (Oregon Health Authority) with associated 38% reduction in poisoning events --------------------------------------------------- 11% of 8 million chronic opioid users that received potentially innapropriate prescription
$12.20 $19.40 Reduce prescriptions - both # of Rx and quantity per Rx
Provider education to reduce # and quantity Reporting for MME ordered
Current supply Provider buy-in
Overdiagnosis Reduce Cost to Top 5-10 Diagnoses by 25% (breast cancer screening, pre diabetes, ckd, asthma, hypertension, CDI)
HARD PAYOR $345 per mammogram; $6283 per CKD case; $2560 per hypertension case; $511 per pre-diabetes case; $4166 per asthma case, $750 (drug costs) per CDI case (claims data)
Assumed 25% reduction across all cases/tests
$67.80 $67.80 Overdiagnosis: pick top 5 or 10 diagnoses; assume 25% reduction; find average cost of treatment
Advocacy - NNTH/B, publication bias Education; Campaign Local systems/design
Belief, Inertia
What is Muda?
• Muda (無駄) is a Japanese term for anything that is wasteful and doesn't add value. It is also a key concept in the Toyota Production System. Waste reduction is an effective way to increase profitability.
• A process adds value by producing goods or providing a service. A process also consumes resources. Waste occurs when more resources are consumed than are necessary to produce the goods or provide the service.
1. Standardize Model
Map Process
Understand variation
Redesign process
Do you
have a
standard
care
model?
No
Yes
2. Optimize Efficiency
Track the costs of the care
process
Reduce waste, improve
performance
Key Concepts • Simplification
• Coordination
• Substitution
• Improved
decision-making
A Framework to Continuously
Improve Value by Reducing
Cost & Improving Quality
3. Leadership
Decision
Making
Check Continuously: Is quality high and
consistent?
Is staff engagement high?
What is the impact on job
satisfaction?
IHI R&D, 2016
Hamad Medical Corporation – 9 teams 74
Initia
l P
ilot
Heart Hospital:
Cardiac step-down
F
irst sp
rea
d u
nits
Heart Hospital:
Cardiac ICU + imaging
Se
co
nd
sp
rea
d p
ha
se
Six additional teams in four sites
Results, cont. 75
UCL
LCL
0
2000
4000
6000
8000
10000
12000
14000
16000
1 2 3 4 5 6 7 8 9
10
11
12
13
14
15
16
17
18
19
20
21
Overtime cost (RNs) Measure
Improved
scheduling
Waste
• Do you have a means to “see” waste in your
system?
• How are you balancing top-down versus bottom-up
solutions?
• How can you further build the will for change here?
• What leadership driver do you most need to
enhance?
76
Safe Care
• Understanding safety performance now and
improving
• Seeing diagnostic error
• Looking across the system
77
Diagnostic Errors
• Affect 1 in 20 adults
• Leading cause of malpractice claims
– 29% of total suits from 1986-2010
• Leads to delays in treatment and increases cost
of care
Source: https://www.modernhealthcare.com/article/20190126/NEWS/190129972/coalition-tackling-diagnostic-errors-gains-some-
traction
Six Barriers to Accurate Diagnosis
1. Poor communication during care transitions
2. Lack of measures and feedback
3. Limited support to help with clinical reasoning
4. Limited time
5. It’s complicated
6. Lack of funding for research
Source: The Society to Improve Diagnosis in Medicine. https://www.improvediagnosis.org/new_posts/40-healthcare-organizations-
launch-unprecedented-effort-to-improve-accuracy-and-timeliness-of-diagnosis/
79
Increased Fall Risk
• Number of fall related ED visits by people 65+ increased by 38% in California between 2010 and 2015
• Fall related medical costs total more than $31 billion each year nationally
• Problem will be further exacerbated as baby boomers age
Source: Gorman, Anna. "ER Visits Linked To Falls Spike Among California Seniors." California Healthline. 15 Feb. 2017.
80
CAPABLE
• “Community Aging in Place, Advancing Better Living for Elders” – Emphasizes helping older adults maintain independence through environmental
adaptations and interventions
– Team of nurse, occupational therapist, and handyman
• Common fixes: – 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 times
• 79% of initial participants reported fewer activity of daily living
limitations
Source: 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).
81
CAPABLE
• Roughly $3,000 in program costs yields approximately $10,000 in savings in medical costs.
• Participants showed reduced symptoms of depression, fewer difficulties with Activities of Daily Living, and improved motivation.
Source: 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).
82
How do you “see” harm in hospital
care?
• Do you have a dosing formula and a method to share
best performance quickly and to all?
• Have you shared the story (like Gilbert), the
extrapolation, the human cost, and the financial cost?
• Can you measure harm across the system?
• What’s the leadership driver you most need to enhance?
85
Deming and Joy in Work
“Management’s overall aim
should be to create a system
in which everybody may take joy in his
work.”
– Dr. W. Edwards Deming
87 The Burning Platform
Source: www.nam.edu/perspectives
Measurement
IHI Organizational Diagnostic
Joy in Work
• Have you used your data to predict and plan for a vibrant workforce?
• How are you doing on psychological safety, meaning, sense of control and recognition?
• How are you building effective teams and creating cameraderie?
• Which of the leadership drivers are most relevant here?
92
New Ways to Codesign Care with
Patients and Families
93
Patient-Centered Redesign – Self Dialysis
• Self-dialysis transformation began in 2005 at Ryhov Hospital in Jönköping, Sweden
• Christian asked about doing his own dialysis, then taught another patient, and the program grew
• Now 70% of dialysis patients at the hospital perform their own treatments
• Self-dialysis is performed at 50% of costs of other hemo-dialysis units
Waco, Texas
• Patients were taught to self-administer care at the CTNA clinic
• In 2016, almost 40% of CTNA’s 751 patients performed their own
dialysis
• They also experienced fewer hospitalizations and a lower mortality
rate
• Staff burden shifted from performing each step of dialysis to serving
as coaches and supporters of patients performing self-care
95
Source: https://hbr.org/2017/06/the-value-of-teaching-patients-to-administer-their-own-care
My Dialysis, My Choice
The patient starts by
selecting a few values
that matter most to them
when choosing a
treatment plan
Then detailed information
is provided to help the
patient rate treatment
options according to how
well they match each
chosen value
Source: mydialysischoice.org
My Dialysis, My Choice Based on the patient’s rankings on each value, the
results are compiled to help them decide which dialysis
treatment option is best for their lives and health
Source: mydialysischoice.org
Royal Free Hospital, London
“Maximising kindness and friendship towards patients through systematic staff development, environmental design and clinical practice.”
98
Key Results
• Unit length of stay reduced by 2.6 bed days
• 26% reduction in readmissions
• 49 % of patients initially labelled as ‘now needs nursing
home’ converted to ‘return to their previous home’
99
June 4, 2014
Brazil Scotland Norway
Italy Denmark BC Canada
Global Reach of WMTY
Kindness Bundle
• Opening and closing interactions with patients in a structured way
• Warm personal introduction – “What would you like me to call you?”
• Shared decision making – “What matters to you?”
– “What about today? What would make today a good day?”
• Warm close-out – “Is there anything we can do to make you more comfortable?”
Source: Galina Gheihman, MD and Cynthia Cooper, MD
Basic Acts of Kindness Can Lead To
• Faster wound healing
• Reduced pain, anxiety and blood pressure
• Shorter hospital stays
105
Source: Berry, L. (2018, April 8). Some basic acts of kindess found to help patients dealing
with cancer. The Washington Post. Retrieved from https://www.washingtonpost.com/
Basic Acts of Kindness
• Deep listening
• “What’s the matter?” “What matters to you?”
• Empathy
• Anticipatory kindness based on patient’s situation and stressors
• Generous acts
• Can offer a renewing buffer to emotional fatigue and stress
• Timely care
• Institutional commitment to being on time
• Gentle honesty
• Guide patients to intrinsic hope
• Support for family caregivers
• Prepare, empower, and assist a patient’s family
106
Source: Berry, L. (2018, April 8). Some basic acts of kindess found to help patients dealing
with cancer. The Washington Post. Retrieved from https://www.washingtonpost.com/
What are the leadership opportunities to build
and optimize patient-centered redesign?
• Have you launched ‘What Matters to You’ Day (June 6,
2019)?
• How do you hear the voice of patients and families in design?
• Does your culture support shifting the balance of power?
Using all of the assets of patients and families?
• Which of the leadership drivers are most important here?
Report out
• We heard
• We learned
• We’ll lead differently by……..
109
شكرا Maureen Bisognano
President Emerita and
Senior Fellow
Institute for Healthcare
Improvement
53 State Street, 19th Floor
Boston, MA 02109
Derek Feeley
President and CEO
Institute for Healthcare
Improvement
53 State Street, 19th Floor
Boston, MA 02109