The Doctor and the Sheriff 20th Annual International Forum on Quality and Safety in Healthcare

April, 22, 2015

London, UK

Maureen Bisognano President and CEO

The IHI Triple Aim

A Few Years Ago

“The secret of the care

of the patient is in caring

for the patient.”

-Francis Peabody

Toolkit to Care

1. Curiosity

The Doctor

The Human Cost of Preterm Births

Infant mortality rate for preterm births before

32 weeks of pregnancy is 70 times greater

than the infant mortality rate for infants born

between weeks 37 and 41.

Johnson, Steven Ross. "Mothers' Helpers: Providers, Insurers Use Home Visits to Reduce Infant Mortality." Modern

Healthcare. Modern Healthcare. Crain Communications, Inc. Web. 16 Mar. 2015.

<http://www.modernhealthcare.com/article/20150314/MAGAZINE/303149941>

Average medical cost for a baby from birth

through first year of Life

Healthy, full-term baby from birth through the first year

$5,085 Premature and/or low-birth weight baby (less than 37

weeks gestation and/or less than 2.5 kg)

$55,393

The Financial Cost of Preterm Births

Johnson, Steven Ross. "Mothers' Helpers: Providers, Insurers Use Home Visits to Reduce Infant Mortality." Modern

Healthcare. Modern Healthcare. Crain Communications, Inc. Web. 16 Mar. 2015.

<http://www.modernhealthcare.com/article/20150314/MAGAZINE/303149941>

18

21

48

47

29

33

26

10

38

8

9

125

44

95

81

44

23

5

5

132

8

103

52

22

40

37

5

19

11

7228

15

12

94

64

10

81

1832

108

64

26

39

12

286

141

20

45

30

12

57

24

22

33

13

25

696

15

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8th

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Wal

do

University

75th

23rd

24th

43rd

Newberry

15th

331

20th

Hawthorne

55th

2nd

Williston

91st

98th

121

27th

63rd

31st

41st

4th11t

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Lakeshore

Depot

2082Rocky Point

Millhopper

74th

2nd

8th

63rd 39th

23rd

63rd

43rd

43rd

23rd

16th

6th

23rd

15th

32609

32608

32641

32607

32653

32606

32605

32667

32601

32603

32611

G A I N E S V I L L E , F L : M E D I C A I D B I R T H D E N S I T Y A N D C O U N T B Y C E N S U S B L O C K G R O U P ( 2 0 0 7 - 2 0 0 9 )G A I N E S V I L L E , F L : M E D I C A I D B I R T H D E N S I T Y A N D C O U N T B Y C E N S U S B L O C K G R O U P ( 2 0 0 7 - 2 0 0 9 )

0 - 16

17 - 30

31 - 45

46 - 59

60 - 74

75 - 89

90 - 103

104 - 11

8

119 -

132

133 - 147

148 - 162

163 - 176

177 - 191

192 - 205

206 - 220

221 - 235

236 - 249

250 - 264

265 - 278

279 - 293

294 - 308

309 - 322

323 - 337

338 - 351

352 - 366

Color Legend:Approximate Number of Medicaid Births per Square Mile

Census Blockgroups with less than 5 Medicaid Births are not labeled.

This map shows the distribution of 2,760 Medicaid Births.

Mobile Outreach Clinic Stops

The Doctor and the Sheriff

High Density Low Density

Density of Child Maltreatment (2005-2008) Density of Domestic Violence

Homeless Children Previous Address (2010)

Mobile Outreach Clinic

Mission

- Provide a clinical education to health students (undergraduate and graduate)

- Promote a culture of service

- Provide health care access to the medically underserved in our community

Health Outreach Quality Improvement (HOQI) Program

Created in Fall 2012 for undergraduate pre-professional students at UF

Unique volunteering opportunity for students

Hands-on learning experiences at clinic

- Provide service that paid employees provide in our health science center clinics

- Key role in coordinating care and services for patients outside of clinic visit

Weekly commitment of 3-4 hours in clinic alternating with care coordination

How to do local needs assessments and

communicate results

How clinicians can screen, diagnose, and

help/hurt victims of Intimate Partner Violence

(IPV)

How to do diagnostics in a low resource

environment

Local food insecurity; “food deserts”

Mobile Outreach Clinic Student Reflections

Understanding literacy among our patients

Transportation barriers for rural Alachua County

and parts of greater Gainesville

Awareness of how to find local resources for

special populations

Broad cultural sensitivity and humility, not

race/ethnicity alone, but social and

environmental disparities as well

Mobile Outreach Clinic Student Reflections

The Importance of Curiosity

IQ – Intelligence Quotient

processing 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 Quotient

inquisitive, open to new experiences, finding novelty exciting

Chamorro-Premuzic T. “Curiosity Is as Important as Intelligence.” Harvard Business

Review. Aug 27, 2014.

Toolkit to Care

1. Curiosity

2. Improvement Skills

233,057 students and residents registered on IHI.org

216,794 students and residents have completed 1.6M

courses

41,604 students and residents have earned their

Basic Certificate of Completion

716 chapters in 70 countries

IHI Open School Online Resources

• Improvement Stories

• Tools

• Publications

• Case Studies

• Video Interviews

• Audio Clips

• Posterboards

• Weekly Newsletter

Going Viral

http://www.ihi.org/resources/Pages/AudioandVideo/MikeEvansVideo

QIHealthCare.aspx

https://www.youtube.com/watch?v=jq52ZjMzqyI&list=UUL-

IWPkXQn3JYYYsPnpGlIg

Helen Bevan’s FUNdamentals

Going Massive

A new Coursera MOOC

developed with Fred Southwick

at Univ. of Florida

reached 6,833 students from

150 countries over its eight-

week course.

And IHI is developing its own MOOC in collaboration with HarvardX and

the Harvard School of Public Health. Content for this first course will

include the principles and practices of quality improvement.

We’re planning for future courses on organizational change

management, qualitative and quantitative improvement and research

methods, systems engineering, IT-enabled improvement, and

leadership.

Building Your Own Skills

Learn how to improve in your daily

work

Move from “fix and forget” to “see,

solve, and share”

Learn to ask “what matters to you?”

Hewitt TA, Chreim S. BMJ Qual Saf Published Online First: [10 Mar 2015] doi:

10.1136/bmjqs-2014-003279

Toolkit to Care

1. Curiosity

2. Improvement Skills

3. Teamwork

Saskatoon:

“Forecast model to predict surges in health care demand.” Saskatoon Health Quality Council Blog. Available at:

http://blog.hqc.sk.ca/2015/04/07/forecast-model-to-predict-surges-in-health-care-demand/

Admission-Discharge Ratio

This is knowledge that would be wasted otherwise

Improving With Your Team

Using huddles to:

Innovate

Spread

Exnovate

Innovation

Where are care models and processes broken?

Where do we need new thinking?

Innovation labs, design processes

Harvesting

Spread

Where do we see variation in performance?

How can we reliably spread to ensure that we

can provide the best care to every patient, where

they are?

Transparent data

Curiosity

Spread Model

Exnovation

How do we stop what doesn’t work anymore?

How will we eliminate wasteful practices and

processes?

It takes courage!

IHI Leadership Alliance

Radical Design Principles

Design systems that expect and embrace change

Change the balance of power

Cultivate joy in work

Make it easy

Move knowledge, not people

Cooperate and collaborate

Assume abundance

Return the money

Berwick DM, Feeley D, Loehrer S. Change From the Inside Out: Health Care Leaders

Taking the Helm. JAMA. Published online March 26, 2015.

doi:10.1001/jama.2015.2830.

Primary Children’s Hospital Salt Lake City, Utah

New Team Members

Using all of the assets in our communities

“Altogether Better” – 20,000 young health champions-

working to achieve the Triple Aim

Simon Stevens calls our patients, the volunteers and our

communities are “renewable energy” that are “central to our future”

In Bradford working with other people in Bangladeshi

communities “Seniors show the way”

Young people using social media to talk about health and

happiness

The Future is Now. The King’s Fund. 2015. available at:

http://www.kingsfund.org.uk/reports/thefutureisnow/

Who Recommends Why

Solid tumor oncologist Hormone therapy, Adjuvant

Radiotherapy (aRT)

Right Away

High risk. Stop the cancer

first, worry about side

effects second

Surgeon Watch and Wait. If you get

biochemical recurrence the

do Salvage radiotherapy

(sRT)

Side effects on top of

surgery are not good – and

you may not need radiation

(10%-20% chance). Delay

the side effects.

Radiation oncologist Hormone Therapy, (aRT)

Right Away

Young, High Risk

AUA aRT right away High Risk

Pelvic floor physical

therapist

Think very carefully before

having radiation

Deals with side effects

everyday

Fragmentation: A Patient’s View

East London

WHO Collaborating Centre:

Unit for Social and Community Psychiatry

Toolkit to Care

1. Curiosity

2. Improvement Skills

3. Teamwork

4. Taking Care of Yourself

100 Million Healthier Lives

Mission:

100 Million People Living Healthier Lives by 2020

100 Million Healthier Lives

Who We Are

100 Million Healthier Lives is an unprecedented

collaboration of change agents pursuing an

unprecedented result:

100 Million People Living Healthier Lives by 2020

Well-being At

HealthPartners

Toolkit to Care

1. Curiosity

2. Improvement Skills

3. Teamwork

4. Taking Care of Yourself

“Fit to play, fit to learn”

St Ninians Primary School

Stirling Scotland

Ms Elaine Wyllie wylliee48s@stirling.gov.uk

The Improvement Issue

The Provocation St. Ninians 2012: A school volunteer commented on how unfit the children looked P.E teacher confirmed that many pupils were exhausted by the warm up stage of the P.E class.

An inconvenient truth

51

•Our School friend ....81 •He has his own castle and estate •Hosts Famous Five nurture days •2 chess clubs + individuals • Storytelling, poetry, recitation penny whistle

I wonder? (Test 1)

• Could the children run round the field

a few times each day to get fit?

• Took 1 class on 1 day out to run round the field a few times to see what would happen?

• Many ‘couldn’t run the length of themselves.’

• Almost all of the children could only manage scout’s pace. It was true – they were not fit.

How the Daily Mile Works

• Children go out in almost all weathers • Context driven time chosen by the teacher • Easy to fit in to the day -fifteen minute turnaround max -no need to change into Exercise kit -no training for teachers – it is simple -it’s FREE! • regularly refreshed – e.g. links to national sporting

events and to the curriculum • Integrated with policy educational activities (IDL)

many links made

Linked to the curriculum

Health and Well Being , Better movers and Thinkers, maths, topic: the polar bear big swim, world city marathons, The Daily Nile, etc, etc….

Measurement

• Each child / class plans their own approach to the Daily Mile and tracks their own performance.

• measurement and goals vary and are suggested by the children and the class teacher.

• Qualitative feedback from pupils, teachers and parents.

The Impact

• Inclusive of all children

• Improved focus

• Children thrive on being outdoors – experiencing the fresh air, the weather, the sights and the sounds

• ALL 420 Children in the school are fit and able to get the most out of their PE sessions

• Running and building relationships

• Children are very positive about it

and proud of it

57

• Parents are grateful that the school keeps their children fit and that it relieves feelings of guilt

• Children are sleeping better • Children are eating better • Parents from two classes not

doing the Daily Mile regularly enough!

• Parents lead our running club • The new school

Parental feedback

58

• The children love being outside

• Cross-curricular learning benefits – e.g. Maths / Topic work

• It supports the rhythm of the classroom and the day

• the children’s confidence has increased

• Children are focussed and ready to learn when they come back into the classroom

• Relationships

Feedback from staff

Aim: To create an opportunity to get children fitter by running a mile

everyday at St Ninians School, Stirling in Scotland by June 2012

A P

S D

A P

S D

Cycle 1a: Begins with ME! Test the Daily mile with Head Teacher and 1 class on 1 day at a Scout Pace (20 running 20 walking)

Cycle 1c:Test the daily mile with 1 class for 1 week adjustments for clothing and footwear

Cycle 1e:Test the daily mile for 3rd week and get other classes ready for testing

Cycle 1d:Test the daily mile with a measurement system for 2 weeks more running than walking

Cycle 1b Test the daily mile with one class for 1 day with a willing teacher Primary 6 Class

Process Change: To introduce the Daily Mile with the Primary 6 Class

Changes

A P

S D

A P

S D

Cycle 2a:Test the Daily mile with 2 classes new classes start at a Scout Pace

Cycle 2c: Test the daily mile including all classes

Cycle 2e:All classes participating including nursery

Cycle 2d:Test the daily mile with Nursery class

Cycle 2b Test the daily mile with 4 classes

Process Change: To introduce the Daily Mile ALL other classes

Changes

Aim: To create an opportunity to get children fitter by running a mile

everyday at St Ninians School, Stirling in Scotland by June 2012

Essence of the Change

Keep people well

Keep people whole

Support health and well-being

Make it easy

When needed, best care in hospital

Ask, “What makes a good day?”

Caring at the End of Life

“What’s a good day for you?”

Toolkit to Care

1. Curiosity

2. Improvement Skills

3. Teamwork

4. Taking Care of Yourself

Thank You!

Maureen Bisognano

President and CEO

Institute for Healthcare Improvement

20 University Road, 7th Floor

Cambridge, MA

mbisognano@ihi.org