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Leading Transformational Change
 

Leading Transformational Change

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Maureen Bisognano's presentation at SCHA's Patient Safety Conference in Columbia, SC 2010.

Maureen Bisognano's presentation at SCHA's Patient Safety Conference in Columbia, SC 2010.

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    Leading Transformational Change Leading Transformational Change Presentation Transcript

    • Leading Transformational Change: The Big Picture South Carolina Hospital Association 2010 Patient Safety Symposium Columbia, SC Maureen Bisognano Executive Vice President and COO Institute for Healthcare Improvement
    • Objectives After this session, participants will be able to: ─Identify key drivers for leaders seeking to thrive in a new environment ─Define a portfolio of new designs that will improve patient health and experience and drive down costs
    • Health Care Expenditure Out of GDP
    • Difficulty Getting Care on Nights, Weekends, Holidays Without Going to the Emergency Room, Among Sicker Adults Percent of adults who sought care reporting ―very‖ or ―somewhat‖ difficult 2005 2007 United States International Comparison Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
    • HEALTHY LIVES Mortality Amenable to Health Care Deaths per 100,000 population* 150 1997/98 2002/03 134 130 128 116 115 113 115 109 106 99 97 97 100 88 89 89 88 81 84 76 103 103 104 110 50 90 93 96 101 77 80 82 82 84 84 71 71 74 74 65 0 lia ly nd ria y k n ce d l e m es d en da ay s n ga an ec ar nd an ai pa an It a do ra an at la st rw ed na r tu Sp nm e m nl al la Ja Ir e st St Au ng Gr Fr No Ca Sw r Fi Ze er Po Au Ge De d Ki th ite w Ne d Ne Un ite Un * Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. See report Appendix B for list of all conditions considered amenable to health care in the analysis. Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee 2008). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 5
    • http://www.commonwealthfund.org/Maps-and-Data/State-Scorecard-2009/DataByState/State.aspx?state=SC
    • South Carolina HSMRs Regression-Adjusted Hospital Standardized Mortality Ratios (HSMRs) for South Carolina Hospital Referral Regions (HRRs) 120 110 Regression Adjusted HSMR 100 Charleston HRR Columbia HRR 90 Florence HRR 80 Greenville HRR Spartanburg HRR 70 USA Medicare 60 50 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year
    • So What If . . . • Together, in this room, we set out to be as safe as Ascension, or safer? • Together, we design care across the boundaries of our buildings? • Together, we engage all to make our families, friends, and staff healthier? • Together, we show Washington that better care can cost less?
    • So What If . . . • Together, in this room, we set out to be as safe as Ascension, or safer? • Together, we design care across the boundaries of our buildings? • Together, we engage all to make our families, friends, and staff healthier? • Together, we show Washington that better care can cost less?
    • Ascension Health’s Strategy • Health care that works • Health care that is safe • Health care that leaves no one behind ─No preventable deaths by July 2008 across the entire Ascension system ─No preventable harm by July 2008 across the entire system Pressure ulcers Falls with harm Medical errors Birth trauma
    • Mortality Reduction Driver Diagram Primary Drivers Secondary Drivers Analysis of mortality causes 2x2 review of last 50 patient deaths Leadership Global Trigger Tool review of patient deaths in boxes 3 and 4 Board review on mortality Standardization of patient handoffs Communication SBAR training for clinical staff & physicians Multi-disciplinary rounds between caregivers Identification of attending physician for all patients Reduce mortality Implement birth bundles Identification of high risk patients on admission and by 12% during assessments this year High risk patient care Rapid Response Team Increased nursing and physician care Hospitalists Multi-disciplinary rounds Daily goal sheets Ventilator bundle Intensive/Critical care Glycemic control Remote monitoring of patients Intensivists Influenza vaccine status of pneumonia patients Community partnerships to promote care that prevents Prevention critical illness Eliminate falls with harm Eliminate pressure ulcers
    • Perinatal Safety (Birth Trauma) Seton Medical Center – Austin, TX St. Mary’s Medical Center – Evansville, IN Alpha Spread Ascension Health System Birth Traum a Rate Unfavorable S t. M ary's B irth T rau m as - C Y2005 4.5 20% Birth Traum a Rate Goal for As cesnion Health = 0 /1000 Births 18.87% 4.0 D e liv e rie s 17.36% 16.00% 3.5 15% N = 32 N = 33 13.95% 3.03 IHI Target Birth Trauma Rate = 3 /1000 Births 2.97 12.69% Birth Trauma Rate per 1000 Live Births 12.06% 12.50% 3.0 N = 36 2.68 N = 35 10.30% 10.58% 10% 2.52 9.15% 8.63% 2.5 P e rc e n t 7.26% 2.0 5% 1.84 1.97 N = 36 1.26% 2.99% 1.5 1.82% 0.61% 1.39% 0.71% 1.32% 1.61% 1.92% N = 35 0.72% 0.00% 0.00% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1.0 Jan Feb Mar A pr May Jun Jul A ug Sep Oc t Nov Dec National Birth Trauma Rate = 6.59 /1000 Births 0.5 -5% 0.0 2005 Jan-06 Feb-06 Mar-06 Month Apr-06 May-06 Jun-06 Favorable Birth Trauma Rate per 1000 Live Births Linear (Birth Trauma Rate per 1000 Live Births) Ins trum ent-A s s is ted Deliveries S houlder Dy s toc ia B irth Traum a N = Number of Reporting Hospitals Zero!
    • Reducing Harm in the ICU Ventilator Acquired Pneumonia St. Vincent’s Hospital, Birmingham Alpha Spread Ascension Health System System Trend VAP Rate ICU/CVICU Combined VAP Rate Unfavorable Ascension Health Goal is 0 VAP per 1000 Ventilator Days 4.5 16 4.0 14 N = 43 NNIS Average = 4.15 VAP per 1000 Ventilator Days 3.55 12 3.5 VAP rate Per 100 Vent days NNIS Average = 4.15 VAP per 1000 Ventilator Days N =43 VAP rate Per 100 Vent days 3.03 10 3.0 N = 43 N = 42 8 2.63 2.50 2.53 2.5 6 N = 44 2.25 2.0 4 N = 43 2 1.5 1.68 N =39 0 1.0 11/1/2004 5/1/2004 7/1/2005 7/1/2004 9/1/2004 1/1/2005 3/1/2005 5/1/2005 9/1/2005 1/1/2006 3/1/2006 5/1/2006 7/1/2006 11/1/2005 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Month Favorable Vap Rate per 1000 ICU Vent days Linear (Vap Rate per 1000 ICU Vent days) N = Number of Reporting Hospitals Zero!
    • Reducing Harm in the ICU Blood Stream Infections St. John’s Hospital, Detroit Alpha Spread Ascension Health System BSI Rate System Trend BSI Rate Unfavorable Ascension Health Goal is 0 BSI per 1000 Central Line Days 4.5 10 4.0 9 NNIS Average = 4.22 BSI per 1000 Central Line Days NNIS Average = 4.22 BSI per 1000 Central Line Days 3.5 8 BSI per 1000 Central Line days BSI Rate Per 1000 Central Line days 3.0 7 N = 39 2.33 6 2.5 N =39 5 2.0 1.74 N =35 4 1.37 1.5 1.69 3 N = 39 1.38 1.38 1.35 1.0 N = 38 N =38 N =38 2 0.5 1 0.0 0 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Mar-04 May-04 Mar-05 May-05 Mar-06 May-06 Nov-04 Nov-05 Feb-04 Aug-04 Sep-04 Feb-05 Aug-05 Sep-05 Feb-06 Jan-04 Apr-04 Jun-04 Jan-05 Apr-05 Jun-05 Jan-06 Apr-06 Jun-06 Dec-03 Dec-04 Dec-05 Jul-04 Jul-05 Jul-06 Oct-04 Oct-05 Month Favorable BSI Rate Per 1000 CL Days Linear (BSI Rate Per 1000 CL Days) N = Number of Reporting Hospitals Zero!
    • POAE Rate per Patient M 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 ar -0 Ap 4 r- 0 M 4 ay -0 Ju 4 n- 04 Ju l-0 Au 4 g- 0 Se 4 p- 0 O 4 ct -0 No 4 v- 0 De 4 c- 04 Ja POAE Rate n- 0 Fe 5 b- 0 M 5 ar -0 Ap 5 CL r- 0 M 5 ay -0 Ju 5 n- 05 Ju l-0 UCL Columbia St. Mary's, Milwaukee WI Au 5 g- 0 Perioperative Adverse Event (POAE) Rate Se 5 p- 0 O 5 ct -0 LCL No 5 v- 0 De 5 c- Columbia St. Mary’s - Milwaukee 05 Ja n- 0 Fe 6 b- 0 M 6 ar POAE Rate per Patient -0 Ap 6 r- 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0 M 6 ay -0 Jan-04 6 Feb-04 Mar-04 Apr-04 May-04 Jun-04 Jul-04 Aug-04 Sep-04 POAE Rate Oct-04 Nov-04 Dec-04 Jan-05 Feb-05 Columbia St. Mary’s – Milwaukee, WI CL Mar-05 Sacred Heart Hospital – Pensacola, FL Apr-05 Surgical Complications May-05 Jun-05 Jul-05 Sacred Heart Hospital, Pensacola FL Aug-05 Perioperative Adverse Event (POAE) Rate UCL Sep-05 Oct-05 Nov-05 Sacred Heart Hospital Dec-05 Jan-06 LCL Feb-06 Mar-06 Apr-06 Zero! May-06 Jun-06 Jul-06
    • Pressure Ulcer Prevention Facility Acquired Pressure Ulcer Rate St. Vincent Hospital, Jacksonville Alpha Spread Ascension Health System 50 hospitals reporting: Overall Rate 1.38 National Rate: Overall PU ratio by week U n f a v o r a b le 7.00 2 .0 0 P re s u re U lc e r R a t e p e r 1 0 0 0 P a t ie n t D a y s N = 50 6.00 N = 51 N =50 1 .6 6 1 .6 3 1 .5 7 5.00 N = 50 1 .5 0 1 .3 8 1 .4 8 4.00 1 .4 1 N = 51 N = 50 3.31 1 .2 7 3.00 N = 50 2.78 2.53 2.46 1 .0 0 2.11 2.00 1.93 2.00 1.90 1.68 1.65 1.46 1.47 1.41 1.38 1.39 1.171.17 1.07 1.04 1.001.03 1.03 1.01 1.05 1.05 1.07 1.00 0.94 0.990.99 0.75 0.74 0.69 0.69 0.71 0.71 0.75 0.69 0.67 0.38 0.390.37 0.36 0.32 0.340.33 0.39 0.35 0.39 0.32 0.32 0.37 0.35 0 .5 0 0.00 0.00 Ja n -0 6 Feb-06 Mar-06 A pr-06 May -06 Ju n -0 6 J u l- 0 6 WE 8/29/05 WE 9/12/05 WE 9/26/05 WE 10/10/05 WE 10/24/05 WE 11/7/05 WE 11/21/05 WE 12/5/05 WE 12/19/05 WE 1/2/06 WE 1/16/06 WE 1/30/06 WE 2/13/06 WE 2/27/06 WE 3/13/06 WE 3/27/06 WE 4/10/06 WE 4/24/06 WE 5/8/06 WE 5/22/06 WE 6/5/06 WE 6/19/06 WE 7/3/06 WE 7/17/06 WE 7/31/06 WE 8/14/06 WE 8/28/06 F a v o r a b le M o n th P r e s s u r e u lc e r r a t e p e r 1 0 0 0 In p a t ie n t D a y s L in e a r ( P r e s s u r e u lc e r r a t e p e r 1 0 0 0 In p a tie n t D a y s ) N = N u m b e r o f R e p o r tin g H o s p it a ls Zero!
    • Reducing Harm in the ICU Rapid Response Teams – Non-Critical Care Codes and RRT Calls Borgess Hospital, Kalamazoo Alpha Spread Ascension Health System 33 hospitals reporting: Overall Rate 2.71 Borgess Medical Center Non-Critical Care Code Rate by Month for Reporting Hospitals Non-Critical Care Codes per 1,000 discharges unfavorable 10 3.6 3.56 Non-CC Code Rate Goal for 3.50 3.47 Ascension Health: 0 / 1000 3.4 Rate per 1000 Discharges 3.38 Discharges 8 3.29 3.23 3.25 3.2 3.19 6 3.07 3.0 2.96 2.84 2.85 4 2.8 2.71 2.6 2 n=25 n=27 n=24 n=24 n=22 n=22 n=36 n=34 n=35 n=35 n=35 n=37 n=33 2.4 0 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 favorable Non-Critical Care Code Rate per 1000 Discharges NON-CC CODES (per 1000 disch) N= Number of Reporting Hospitals Linear (Non-Critical Care Code Rate per 1000 Discharges)
    • Error Reduction at Ascension Preventable Error Reduction in rate Pressure Ulcer 95% Neonatal mortality 79% Birth Trauma 74% Ventilator-acquired pneumonia 56% Falls with serious injury 54% Blood-stream infections 32%
    • July, 2008 Update: ―A Partial Success‖ • Ascension set a goal of preventing 900 unnecessary deaths by Summer 2008. • In July, they announced they had, in their estimation, prevented 2,700 deaths – three times their stated goal.
    • Ascension Health: New Aim Healing Without Harm by 2014
    • Palmetto Hospital Mortality Rates
    • So What If . . . • Together, in this room, we set out to be as safe as Ascension, or safer? • Together, we design care across the boundaries of our buildings? • Together, we engage all to make our families, friends, and staff healthier? • Together, we show Washington that better care can cost less?
    • A Case Study From University of Pittsburgh Medical Center (UPMC) • Aims in redesigning care for patients undergoing total joint replacement 1. Patient and family education 2. Less invasive techniques 3. Multimodal anesthesia and pain management techniques 4. Rapid rehabilitation protocols 5. Rapid outcomes feedback (from the patients’ and the providers’ perspectives 6. Creating a learning environment and culture 7. Developing a sense of community, competition and teamwork among patients and between patients, caregivers and staff 8. Promoting a wellness (rather than sickness) approach to recovery DiGioia A, Greenhouse P, Levison T. ―Patient and Family- centered Collaborative Care: An Orthopaedic Model‖. Clinical Orthopaedics and Related Research. 2007: 463; pp: 13-19.
    • Tony DiGioia Dr. Anthony M. DiGioia III, orthopedic surgeon and developer of the patient- and family-centered care program for UPMC, in his office at Magee- Womens Hospital in Oakland.
    • A Case Study From UPMC • New Designs: ─Pre-op testing, teaching ─Coaching meetings with other patients ─Pre-surgery discharge planning ─Strong focus on complete pain management ─―Wellness‖ design in orthopedics unit DiGioia A, Greenhouse P, Levison T. “Patient and Family- centered Collaborative Care: An Orthopaedic Model”. Clinical Orthopaedics and Related Research. 2007: 463; pp: 13-19.
    • Results • Safe: ─Mortality rate: 0% ─Infection rates: 0.3% (0.2% for TKA and 0.7% for THA) ─Zero dislocations ─SCIP compliance: 98% for antibiotics within one hour of surgery DiGioia A, Greenhouse P, Levison T. “Patient and Family- centered Collaborative Care: An Orthopaedic Model”. Clinical Orthopaedics and Related Research. 2007: 463; pp: 13-19.
    • Results • Effective: ─95% of patients discharged without handheld assistance directly to home (national rates: 23-29%) ─99% of patients reported that pain was not an impediment to physical therapy, including same-day-of-surgery physical therapy DiGioia A, Greenhouse P, Levison T. “Patient and Family- centered Collaborative Care: An Orthopaedic Model”. Clinical Orthopaedics and Related Research. 2007: 463; pp: 13-19.
    • Results • Patient-centered: ─ Press-Ganey mean satisfaction score is 91.4% (99th national percentile ranking) with 99.7% positive responses to ―Would you refer family and/or friends?‖ • Efficient: ─ Average length of stay:  2.8 days for TKA (national average is 3.9 days)  2.7 days for THA (national average is 5.0 days) ─ One MD able to perform 8 joint replacements before 2:00pm DiGioia A, Greenhouse P, Levison T. “Patient and Family- centered Collaborative Care: An Orthopaedic Model”. Clinical Orthopaedics and Related Research. 2007: 463; pp: 13-19.
    • Other PFCC Projects at UPMC • Day of Surgery (UPMC Presbyterian) • Human Resources – The New Hire Experience (UPMC Corporate) • Trauma (UPMC Presbyterian) • Wayfinding / Lobby (Magee-Women’s Hospital) • Rheumatology (Children’s Hospital of Pittsburgh) • Minimally Invasive Bariatric and General Surgery (Magee-Women’s Hospital) • Home Health Rehabilitation (Jefferson Regional)
    • So What If . . . • Together, in this room, we set out to be as safe as Ascension, or safer? • Together, we design care across the boundaries of our buildings? • Together, we engage all to make our families, friends, and staff healthier? • Together, we show Washington that better care can cost less?
    • Health Outcomes • 1 in 10 adults in SC has diabetes • 22% of adults in SC smoke (compared with 18.3% nationally) • 65.8% of adults in SC are either obese or overweight (compared with 63% nationally) • 15.1% of adults in SC report having a disability (compared with 12.8% nationally) • Mortality rates amenable to health care are 115.5 per 100,000 compared with 89.9 per 100,000 nationally. • Commonwealth Fund ranks SC 33th in US for Prevention and Treatment in 2009 (in 2007 was ranked 35th)  What if we started with all health care workers in out hospitals like Bellin, and then spread to our families and friends?
    • Health Navigation: Bellin Health The new gateway to Bellin Health. Personal, tailored treatment to individuals’ needs, learning styles and lifestyles.
    • Bellin Health Cost of Employee Plan vs. Averages Bellin Health Solutions Program Introduced Funded Personal Benefit Accounts began ($500/$1000)
    • So What If . . . • Together, in this room, we set out to be as safe as Ascension, or safer? • Together, we design care across the boundaries of our buildings? • Together, we engage all to make our families, friends, and staff healthier? • Together, we show Washington that better care can cost less?
    • What If . . . We took on Tom Nolan’s challenge to limit spending growth to 3% per year?
    • The Triple Aim Population Health Experience Per Capita of Care Cost
    • The Triple Aim • Improve Individual Experience • Improve Population Health • Control Inflation of Per Capita Costs The root of the problem in health care is that the business models of almost all US health care organizations depend on keeping these three aims separate. Society on the other hand needs these three aims optimized (given appropriate weightings on the components) simultaneously. --- (Tom Nolan, PhD)
    • HealthPartners TRIPLE AIM: Health-Experience-Affordability 100% 1.006 1.0005 HealthPartners Clinics 37% 98% 97% 0.986 33% 95% Total Cost Index 0.966 25% 0.946 90% 17% 0.926 85% 9% 0.9088 0.906 9% 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q08 2Q08 3Q08 4Q08 1Q09 2Q09 3Q09 Total Cost Index % patients with Optimal % patients “Would Diabetes Control* Recommend” HealthPartners (compared to statewide average) * controlled blood sugar (per ICSI guideline A1C changed Clinics < 1 is better than network average from < 7 to < 8 in 1st quarter 2009), BP & cholesterol, AND daily aspirin use, AND non-tobacco user
    • Domestic Triple Aim Sites • Hospital-Based Systems • Health Plans Cape Fear Valley (NC) Blue Cross Blue Shield of Michigan (MI) Bellin Health (WI)* CareOregon (OR)* Cincinnati Children’s Hospital Medical Center (OH)* Eastern Carolina Community Plan (NC) Genesys Health (MI) (Ascension)* New York-Presbyterian System SelectHealth, LLC ThedaCare (WI) (NY)* • Integrated Health Systems UPMC Health Plan (PA) Group Health (WA)* Independent Health (NY) HealthPartners (MN)* Wellmark (IA) Kaiser Permanente, Colorado Region (CO) Kaiser Permanente, Mid-Atlantic Region (MD) • Public Health Department Martin’s Point Health Care (ME) King County Department of Public Health (WA) Presbyterian Healthcare (NM) • State Initiative Southcentral Foundation and Alaska Native Medical Center (AK) Vermont Blueprint for Health (VT)* Veterans Health System: • Safety Net  VISN 10—Cincinnati VAMC (OH) Colorado Access (CO)  VISN 20—Portland VAMC (OR) Contra Costa Health Services (CA)*  VISN 23—Nebraska, Western Iowa VAMC (NE) North Colorado Health Alliance (CO)* Primary Care Coalition Montgomery County (MD)* Queens Health Network (NY)* • Employers/Businesses QuadGraphics/QuadMed (WI)* • Social Services Common Ground (NY) * Sites that participated in the first phase of Triple Aim Prototyping.
    • International Triple Aim Prototyping Sites • Jonkoping (Sweden) • NHS Salford PCT (NW England) • NHS Blackburn With Darwen PCT (NW England) • NHS Somerset PCT (SW England) • NHS Bolton PCT (NW England) • NHS Swindon PCT (SW England) • NHS Bournemouth and Poole (SW England) • NHS Tayside (Scotland) • NHS East Lancashire Teaching PCT (NW • NHS Torbay Care Trust (SW England) England) • NHS Blackpool PCT (NW England) • NHS Eastern and Coastal Kent PCT (South • NHS Bury PCT (NW England) East Coast England) • NHS Central Lancashire PCT (NW England) • NHS Forth Valley (Scotland) • NHS Sefton PCT (NW England) • NHS Heywood, Middleton and Rochdale PCT • NHS Warrington PCT (NW England) (NW England) • NHS Western Cheshire PCT (NW England) • NHS North Lancashire Teaching PCT (NW England) • NHS Wirral PCT (NW England) • NHS Medway (South East Coast England) • State of South Australia, Ministry of Health (Australia) • NHS Oldham PCT (NW England) • Western Health and Social Care Trust (Northern Ireland) Last Updated 7/21/09
    • Leadership Driver Reduce medical errors and harm Diagram for Improve Thriving Under Reduce “never events” Reform Safety Chronic conditions self-management Prevention and wellness (start with your staff) Engage Transparency for high-performing providers Patients Shared decision making Thriving New models for medically complex patients Under Palliative care improvement Reform Reduce artificial variation (LOS, use rates, readmissions, etc.) Improve Eliminate “flow faults” Efficiency Set a goal of reducing waste by 1-3% of operating expense budget for I year, year on year Create a culture of getting value for money Leadership Adopt a proactive approach to errors and harm to reduce malpractice claims and costs Engage the Board
    • Thank You! • Maureen Bisognano Executive Vice President and COO Institute for Healthcare Improvement 20 University Road, 7th Floor Cambridge, MA mbisognano@ihi.org 617-301-4800