Learning to
See
2013 NHS Scotland Event
Plenary Session
11 June 2013
Glasgow
Maureen Bisognano
President and CEO
IHI
Chinese Proverb
不闻不若闻之,闻之不若见之,见之不若知
之,知之不若行之;学至于行之而止矣
“I hear and I forget; I see and I remember; I
do and I understand”
-...
Today‟s Busy Life
Frenetic schedules
Too little sleep
Pathologic addiction to devices
Challenges for Today
Seeing the whole system
Seeing data and using to predict
Seeing all the assets the patients and famil...
Four Themes
Reliability
Resilience
Empathy
Promises
JetBlue – A Great Start and Challenges
Founded in 1999
Mission: “to restore humanity to air travel” and to
provide the bes...
JetBlue
Valentine‟s Day Storm (14 February 2007)
A Storm of Problems
On 14 February 2007, an ice storm headed for New York City.
The ice was supposed to change to rain, so...
Recovery…and On to Thrive
“Naming the problem” and simplicity
Prediction
IROPs (Irregular Operations)
Cancel, recover, com...
Value Stream Map Example
Recovery…and On to Thrive
Build empathy and mindfulness
Trained all in what customers experience
Walk through cancellation...
Results
One of the strongest airline brands in the U.S.
Consistent records for customer satisfaction
Staff satisfaction (“...
North Shore-LIJ Center
Provides ambulance service in the 1700 square miles of
New York City, Nassau and Suffolk Counties. ...
Data, Prediction, and Planning
North Shore-LIJ Center for Emergency Medical Services
High Reliability Principles
Preoccupation with failure
Reluctance to simplify
Sensitivity to operations
Commitment to resi...
Your Homework
Study your next meeting
Ask yourself, “Are you looking back at the
past? Or are you looking to the future, t...
Four Themes
Reliability
Resilience
Empathy
Promises
A Tale of Two Patients
Jess
• Team rounds
• Patient drives goal-
setting
• No “visitors” – all are
welcome
• Daily planning with
Jess, her family...
Jess
Bill
• 4 hour journey in
surgery with “wait two
hours”
• “Who let them in?”
• No whiteboard; no
daily plans; no team
commu...
A Tale of Two Patients
Learning to See
Ask not “what‟s the matter?”
Ask “what matters to you?”
SOURCE: Barry MJ, Edgman-Levitan S. ”Shared Decisi...
Your Homework
Sit in on patient rounds
Ask yourself, “Are they „Jess‟ rounds? Or
„Bill‟ rounds?”
Four Themes
Reliability
Resilience
Empathy
Promises
Empathy and Mindfulness
Each team member learned how to speak up – to ask
questions – to offer suggestions
They taught emp...
Empathy
Can we teach empathy? (Yes! And
we must!)
Research shows we are “unteaching”
empathy in our care givers
An Empathy Deficit
Hypotheses for further study:
− Students are seeing themselves at the “bottom of the
hierarchy”. The sy...
Empathy
http://www.youtube.com/watch?v=
cDDWvj_q-o8
Teaching Empathy to the Next
Generation
http://www.ihi.org/offerings/IHIOpenSchool/
overview/Pages/default.aspx
Beth from Minnesota
A quiet, friendly woman in her mid-40‟s
Diagnosed with breast cancer this year
Serious osteoarthritis ...
Lessons for Health Care
With the front line, leaders need to build
reliable processes and build in resilience
for when pro...
Your Homework
Navigate a whole patient journey
Ask yourself, “Do all the „pieces‟ fit
together?”
Do we know “what matters ...
Experience of
Care
Per Capita Cost
Health of a
Population
The Next “Blockbuster” Drug
Pharmacist Medication Reconciliation
at Home
5000
Hours
Source: Asch DA, et al. “Automated Hovering in Health Care – Watching Over the
5000 Hours.” New England Journal...
http://www.ihi.org/offerings/ihiopenschool/resources/P
ages/TrevorAndThePerksOfDiabetes.aspx
Your Homework
Sit in on a patient visit
Ask yourself, “Is it designed for Trevor? Or
would it have let Beth down?”
Four Themes
Reliability
Resilience
Empathy
Promises
“If I could reduce my
message to management
to just a few words, I’d say
it all has to do with
reducing variation.”
- W. E...
Adoption is a SOCIAL thing!
A better
idea…
…communicated through a
social network…
…over
time
Clarify “Where” We Spread
What is your level of our ambition?
Every unit or ward in a hospital?
Every service line (clinic...
Spread Example
TCAB
Changes 6E 6N 7E 7N 7S
RRT
Medication
Reconciliation
Daily Goals
Discharge
Preparation
5S Unit
Supplie...
PCMC Readmission Intervention Complex
Case Management Meeting
2011 2012 # Post-
CCM
ReadmitsJul Aug Sep Oct Nov Dec Jan Fe...
Experience of
Care
Per Capita Cost
Health of a
Population
“It’s more important to know
what sort of person has a
disease than to know what sort
of disease a person has.”
− Hippocra...
Now That You‟ve Learned to See…
Remember Jess, Bill, Beth, and Trevor
Go visit and learn more about the assets
and needs o...
Thank You!
Maureen Bisognano
President and CEO
Institute for Healthcare Improvement
20 University Road, 7th Floor
Cambridg...
Keynote Session 3: Learning to See
Keynote Session 3: Learning to See
Keynote Session 3: Learning to See
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Keynote Session 3: Learning to See

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Maureen Bisognano, President and CEO, Institute for Health Care Improvement.

See more on the 2013 NHSScotland Event website http://www.nhsscotlandevent.com/resources/resources2013/resources

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  • Had the misfortune of experiencing a major ice storm on Valentine’s Day, 2007, a day the folks at JetBlue refer to as “The Valentine’s Day Massacre”
  • Leaders went to system-level prediction, and then to the front line.
  • Let me start with a story of seeing…with apologies to Mr. Dickens, I call it a “Tale of Two Patients”…
  • It takes a face to change a heart, so my first challenge to you is to get out to see, to talk with patients and family members, and to ask not, “What’s the matter?” but instead, “What matters to you?
  • And seeing in new ways needs to happen at every level – our obligation as leaders, policy-makers, as clinicians and carers, is to see all that we need to, and to lead to a culture of caring, and to build robust, reliable systems that have the ability to predict and adjust in a rapidly changing world.
  • So the question for leaders is: “Can we teach empathy?” I’m studying this and the answer is YES! And we must teach it! We owe it to our patients and our clinicians.Research from Boston University and Jefferson University shows that we are doing the opposite – that we are “unteaching” empathy.In the third year of medical school, empathy scores are falling – and researchers are posing several hypotheses for further study, including (next slide):
  • Talking Points for slide:Helen Riess, M.D. has been a leading researcher in the role empathy plays in healthcare for years. Here is a JAMA article from 2010 discussing the important neurobiological effects of empathic behavior.
  • And how many of you are caregivers – physicians, nurses, professionals touching the lives of patients every day?We need new ways to see as well…our job is the Triple Aim – working to improve health, to make care better and safer, and to hold down unnecessary costs.
  • In this sample case, rapid response teams (RRT) were tested at the pilot unit and then rolled out to all four spread units.
  • Keynote Session 3: Learning to See

    1. 1. Learning to See 2013 NHS Scotland Event Plenary Session 11 June 2013 Glasgow Maureen Bisognano President and CEO IHI
    2. 2. Chinese Proverb 不闻不若闻之,闻之不若见之,见之不若知 之,知之不若行之;学至于行之而止矣 “I hear and I forget; I see and I remember; I do and I understand” -Confucius
    3. 3. Today‟s Busy Life Frenetic schedules Too little sleep Pathologic addiction to devices
    4. 4. Challenges for Today Seeing the whole system Seeing data and using to predict Seeing all the assets the patients and families bring Seeing outside the walls Seeing across the data
    5. 5. Four Themes Reliability Resilience Empathy Promises
    6. 6. JetBlue – A Great Start and Challenges Founded in 1999 Mission: “to restore humanity to air travel” and to provide the best overall travel experience including safety and affordability (sounds like the IHI Triple Aim!)
    7. 7. JetBlue Valentine‟s Day Storm (14 February 2007)
    8. 8. A Storm of Problems On 14 February 2007, an ice storm headed for New York City. The ice was supposed to change to rain, so JetBlue continued to let passengers board flights and have those flights taxi out on the runways. The ice never changed to rain and planes were not allowed to take off. Only 17 of JetBlue‟s scheduled 156 flights took off from JFK that day. Passengers were stranded on the runway for 6 hours, and the ripple effect led to days of cancellations (normal operations resumed 6 days later). Estimated cost of the storm‟s disruptions was $41 Million.
    9. 9. Recovery…and On to Thrive “Naming the problem” and simplicity Prediction IROPs (Irregular Operations) Cancel, recover, communicate Engage the front line in solutions Meetings Mapping (“bewildering complexity”) Issues (pink and yellow) Metrics
    10. 10. Value Stream Map Example
    11. 11. Recovery…and On to Thrive Build empathy and mindfulness Trained all in what customers experience Walk through cancellations, wheelchair access, flying with children, etc. Customer “bill of rights” Manage handoffs Quick wins and low-resolution prototypes (QI capability)
    12. 12. Results One of the strongest airline brands in the U.S. Consistent records for customer satisfaction Staff satisfaction (“IROPs is just another day.”) JetBlue faced a much bigger storm in 2012 (Hurricane Sandy), but they came through with minimal disruptions and a cost of only $500,000
    13. 13. North Shore-LIJ Center Provides ambulance service in the 1700 square miles of New York City, Nassau and Suffolk Counties. Employs more than 500 Emergency Medical Technicians and Paramedics who operate over 40 response units each day transporting over 55,000 patients annually.
    14. 14. Data, Prediction, and Planning North Shore-LIJ Center for Emergency Medical Services
    15. 15. High Reliability Principles Preoccupation with failure Reluctance to simplify Sensitivity to operations Commitment to resilience Deference to expertise SOURCE: Weick K, et al. “Organizing for high reliability: processes of collective mindfulness.” Research in Organizational Behavior. 1999.
    16. 16. Your Homework Study your next meeting Ask yourself, “Are you looking back at the past? Or are you looking to the future, to predict and prevent problems?”
    17. 17. Four Themes Reliability Resilience Empathy Promises
    18. 18. A Tale of Two Patients
    19. 19. Jess • Team rounds • Patient drives goal- setting • No “visitors” – all are welcome • Daily planning with Jess, her family, and team, with tollgates • Discharge planning and support
    20. 20. Jess
    21. 21. Bill • 4 hour journey in surgery with “wait two hours” • “Who let them in?” • No whiteboard; no daily plans; no team communication • Sudden discharge
    22. 22. A Tale of Two Patients
    23. 23. Learning to See Ask not “what‟s the matter?” Ask “what matters to you?” SOURCE: Barry MJ, Edgman-Levitan S. ”Shared Decision Making – The Pinnacle of Patient-Centered Care.” N Engl J Med. 366;9. pp 780-782
    24. 24. Your Homework Sit in on patient rounds Ask yourself, “Are they „Jess‟ rounds? Or „Bill‟ rounds?”
    25. 25. Four Themes Reliability Resilience Empathy Promises
    26. 26. Empathy and Mindfulness Each team member learned how to speak up – to ask questions – to offer suggestions They taught empathy by teaching their teams how to see
    27. 27. Empathy Can we teach empathy? (Yes! And we must!) Research shows we are “unteaching” empathy in our care givers
    28. 28. An Empathy Deficit Hypotheses for further study: − Students are seeing themselves at the “bottom of the hierarchy”. The systems they are in lower their self- esteem and they then question their relevance. − For self-protection, students put up barriers and learn “selective empathy”. − The “hidden curriculum” SOURCE: Kowalczyk L. “Empathy gap in medical students.” The Boston Globe. March 25, 2013.
    29. 29. Empathy http://www.youtube.com/watch?v= cDDWvj_q-o8
    30. 30. Teaching Empathy to the Next Generation http://www.ihi.org/offerings/IHIOpenSchool/ overview/Pages/default.aspx
    31. 31. Beth from Minnesota A quiet, friendly woman in her mid-40‟s Diagnosed with breast cancer this year Serious osteoarthritis and bilateral knee replacements in 2009 Depression Overweight Sexually abused throughout childhood Alcoholic from age 16-27 and now sober for almost 20 years In a loving relationship with a partner, now accepted by her family Working in a job she loves What matters to Beth?
    32. 32. Lessons for Health Care With the front line, leaders need to build reliable processes and build in resilience for when processes fail Learn about high reliability and safety, and take these lessons home
    33. 33. Your Homework Navigate a whole patient journey Ask yourself, “Do all the „pieces‟ fit together?” Do we know “what matters to you”
    34. 34. Experience of Care Per Capita Cost Health of a Population
    35. 35. The Next “Blockbuster” Drug
    36. 36. Pharmacist Medication Reconciliation at Home
    37. 37. 5000 Hours Source: Asch DA, et al. “Automated Hovering in Health Care – Watching Over the 5000 Hours.” New England Journal of Medicine. July 2012: 367(1).
    38. 38. http://www.ihi.org/offerings/ihiopenschool/resources/P ages/TrevorAndThePerksOfDiabetes.aspx
    39. 39. Your Homework Sit in on a patient visit Ask yourself, “Is it designed for Trevor? Or would it have let Beth down?”
    40. 40. Four Themes Reliability Resilience Empathy Promises
    41. 41. “If I could reduce my message to management to just a few words, I’d say it all has to do with reducing variation.” - W. Edwards Deming
    42. 42. Adoption is a SOCIAL thing! A better idea… …communicated through a social network… …over time
    43. 43. Clarify “Where” We Spread What is your level of our ambition? Every unit or ward in a hospital? Every service line (clinical & operations)? Every hospital in a system or region? All primary care clinics? All inpatient and outpatient mental health? All levels of care across a population? Throughout Sweden?
    44. 44. Spread Example TCAB Changes 6E 6N 7E 7N 7S RRT Medication Reconciliation Daily Goals Discharge Preparation 5S Unit Supplies Spread to other Med/Surg Units 100% 100% Coverage Completeness SBAR MDR P P P P S S S S S S S S S S P P S S S S S P P=Pilot Unit S=Spread Unit Colors indicate adoption of specific improvements: Green= Implemented Yellow= Testing Red= No Activity
    45. 45. PCMC Readmission Intervention Complex Case Management Meeting 2011 2012 # Post- CCM ReadmitsJul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Patient 1 x x x x CCM 0 Patient 2 x x x x x x x x x CCM 0 Patient 3 x x x CCM x 1 Patient 4 x x CCM 0 Patient 5 x x x x x x CCM x 1 x = Hospital Admission CCM = Complex Care Conference
    46. 46. Experience of Care Per Capita Cost Health of a Population
    47. 47. “It’s more important to know what sort of person has a disease than to know what sort of disease a person has.” − Hippocrates (c. 460 BC – c. 370 BC)
    48. 48. Now That You‟ve Learned to See… Remember Jess, Bill, Beth, and Trevor Go visit and learn more about the assets and needs of your patients and their families It takes a face to change a heart
    49. 49. Thank You! Maureen Bisognano President and CEO Institute for Healthcare Improvement 20 University Road, 7th Floor Cambridge, MA mbisognano@ihi.org

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