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Moving up the curve: Second curve strategies for change

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  • 1. Moving Up Healthcare’s Second Curve: Strategies for Change IE 6 11/6/2012
  • 2. 1st1t2nd 2
  • 3. 3
  • 4. 2nd Curve: an IHI View 4
  • 5. High Reliability in Medicine: Where Do You Need to Be? Future Performance (Second Curve/ 6+ Si Sigma) ) First Curve/ 4 sigma (Craft+Information- mance  Age Culture )  (Craft-AgePerform (Bifurcation  Culture) curve: 2000s) P Flexner 1910 Time             - 5
  • 6. Columns 2 & 3 = 2nd Curve Columns 2+3 = 2nd Curve Regulation Medical Science Management Hammurabi Hippocrates Science   Industrial Legal system Nightingale, 4 doctors Revolution    State Boards Flexner, Codman, Flexner Codman Taylor: “Scientific Scientific  ACS/Hospital Management”  Standardization  JCAHO  Shewhart “Inspection” Inspection M&M conferences    Deming, Juran,  Donabedian,structure Total QualityFed/State regs process, outcome    Complexity theoryORYX, EMTALA, Outcomes, Disease  HIPAA, Etc. management   Lean, Action   Learning, AppreciativeJC, CMS “core Evidence based Inquiry, Adaptive Design, High Reliability, measures,” care, Hospitalists Resilience HCAHPS 6
  • 7. 2 Historical Curves of Health Care Innovation (derived from Kuhn, Toffler, Morrison, Merry) Future Performance (Second Curve/ 6+ Si Sigma) ) First Curve/ 4 sigma Resilience, (Transfer/Sustain mance  2010 Human Momentum)  (Create and Perform (Bifurcation Factors, Factors 2000  Build curve: 2012)  TQM, 1990  Momentum) P Circa 1910 Time             - 7
  • 8. High Reliability and The Performance CurveSafety Culture  Safety  Operating  Sigma Level Operating Level Performance  Performance  Margin Level LevelNeed  Chaotic Below Average 0 None or in AwarenessA deficit d fi itReactive Normal Average 2 2%Implementing Reliable Good  4 5% Performer P fProactive Highly Reliable High Performer 6 10%Generative Ultrasafe Standard‐ 7‐9 20% Setter
  • 9. The Healthcare Reform Paradigm Shift: another View (From David Bates, MD)Current Organization Integrated Care• Incented by volume • Incented by value• Focus on acute illness, high margin services • Focus on prevention, care coordination• Focus on individual patient • Focus on population• Fill beds • Prevent unnecessary admissions, readmissions• Payer has more risk P h ik • Provider has more risk P id h ik >>> HIT will be a key tool!
  • 10. The Three Bucket ModelBucket 1: Optimizing the  Bucket 2: Preparing to  Bucket 3: Moving Up the First Curve Move Up the Second  Second Curve and  Curve Distinguishing Yourself in  the New Landscape of  Healthcare• Lean  • Co‐management • Tri‐management• St d Studer • Di l i th t Dissolving the two siloes il • 3 l 3 column model >>>  d l• Emphasis on  • Service Line  new management  accountability Organization science• EMR • Collaborative Rounding/  g/ • Strategy Learning  gy g• IHI G.L.I.T.C.H. harvesting System• Root cause analysis/ gap  • Safety Culture/ Safety  • Resilient System Design analysis Management System • Systemic Law• PDSA • Relational law Relational law • Systemic thinking Systemic thinking • Adaptive Design • Cross‐ silo information  • Whole‐system Lean (Va.  management: beyond  Mason, Thedacare) silos; manage better the  information we have
  • 11. Leading for ChangeBucket 1: Optimizing the  Bucket 2: Preparing to  Bucket 3: Moving Up the First Curve Move Up the Second  Second Curve and  Curve Distinguishing Yourself in  g g the New Landscape of  Healthcare• Focus on data • Widen the lens: focus on both  • Use information with • Emphasize problem‐solving E h i bl l i qualitative and quantitative  lit ti d tit ti situational awareness, creating  it ti l ti• Root cause analysis information  contextual knowledge• More effective execution of  • Precede problem‐solving with • Combine problem‐solving and  established methods (i.e. for  problem‐finding problem‐finding with problem‐ preventing central line  • Reach out: more information,  framing and situational  infections) wider network, more resilient  deployment (cf. Kim Cameron, FAA) • Add positive deviation, success  • Add appreciative inquiry story analysis, and action  • A shift of assumptions on the  learning/ ongoing  design criteria for care systems  design criteria for care systems experimentation and what performance levels  are possible and necessary  (e.g. from % to Sigma thinking)
  • 12. Buckets 1 & 2: Central Line Infections• Bucket 1: Moving from the assumption of “a a minimal number of inevitable infections that are inherent in the procedure by just applying procedure” known preventive measures more rigorously• Bucket 2: Achieving 0 infections and in so infections, doing, changing our assumptions about achievable performance
  • 13. 1st Curve Breast Diagnosis gInitial Concern Surgery Consult OR/OpenBiopsy OR/O Bi(Cycle time of process Biopsy Readbuilt around practi-tioners: 1 8 weeks) 1-8 Patient Learns 13
  • 14. Bucket 3: 2nd Curve Breast Diagnosis, Park- Nicollet H lth S t Ni ll t Health System, 1995 - P Presentt Screening Xray Immediate Reading Stereotactic Bi S i Biopsy (Cycle time of process f Biopsy Read built around patients: 2 Patient Learns hours possible.) 14
  • 15. Hypothesis: We cannot problem-solveour way to 2nd Curve High Reliability Problem Solving “Appreciative Inquiry” Problem identified Appreciating/valuing best of “What is”   Analysis of causes Envisioning “What might be”   Possible solutions Dialoguing “What should be What be”   Action planning Innovating “What will be”Assumption: Success = Assumption: Success = a problems solved possibility envisioned/created ‐adapted from Bernard Mohr f 15
  • 16. Creating g 2 nd Curve Cultures “Changing how g g2nd Curve Vision work is done changes the g Change Processes culture.” - Jeff Goldsmith, PhD Change S Ch Structures Change Work 2nd Curve Culture 16
  • 17. The Policy Environment: Affordable Care Act• New insurance rules guaranteeing coverage• High risk High-risk pool for people with pre existing conditions pre-existing• Protection for children with pre-existing conditions• Coverage for young adults, to age 26• Small b i S ll business tax credits t dit• Preventive care, free for proven services• Early retirees temporary reinsurance• “Doughnut hole” rebates for Medicare• Annual review of premium increases• Access to care: $ Billions for Community Health Centers and the National Health Service Corps for low-income and uninsured• New incentives for providers (ACOs, CMS rewards and penalties, shared gain provisions) 17
  • 18. “Physician leadership is essential. Physician essentialImproving the value of health care issomething only medical teams can do. . . doPhysicians can lead this change and returnthe practice of medicine to its appropriatefocus: enabling health and effective care.” - Michael Porter, PhD, MBA 18
  • 19. Bucket 3: 2nd Curve Structure InnovationCommunity Memorial Hospital Menomonee Falls, WI 19
  • 20. A 1917 Design, as of 2012 Board of Trustees  Medical St ff E M di l Staff Executive ti Chief Executive Chi f E ti Committee Officer Medical Staff Functions Hospital Functions (“Silo 1”) (“Silo 2”)• Credentialing • Nursing• Departmental (Peer) • Ancillary Specialties Review Departments • Laboratory• Surgical Case Review • Radiology• Blood UR • Physiotherapy• Drug Usage Review • Risk Management• Pharmacy andThe Structure  Finance, Planning 2012: • Hierarchy, Therapeutics • Regulatory Agencies• Medical Records ti Fragmentation, Communication gaps, F t C • Etc. ti i Misunderstanding, Power Struggles, etc. 20
  • 21. “Doctor, I’d like you to resign fromthis di l t ff fthi medical staff for reasons of ill fhealth. You make me sick.” 21
  • 22. The Vision1. Reduce physician time spent in wasteful Medical Staff activities.2. Increase the influence of physicians in the development of service lines and the redesign of clinical g f microsystems.3.3 Clinical microsytems that perform more efficiently and effectively for both patients and caregivers 22
  • 23. The Starting Point Board o Trustees oa d of us ees Quality Improvement Oversight Medical CareMedical Executive Senior Mgt. Team Committee Patient/ OperationalMedical StaffFunctions Community Management Leadership Caregivers 23
  • 24. COMMUNITY MEMORIAL HOSPITAL , Hospital Board Medical Hospital Executive Administration Committee Management and Coordination of Care rative Practice Participation p Management Collabor Leadership Patient/ Design Community Performance Improvement* Specialties provide care in all service lines 24 K:Swp7350(953)miscjanice8.ppt
  • 25. An Emerging Model‐ Suppliers SCS Innovation Strategy  Payors and Funders and Funders Lack of accountability in Hospital  Planning  Increase  Access to centers of  Translate Data into practice excellence Long  waits for Services in  Increase Access  to Outpatient Care the community the community Lack of community services Taking a regional Increase in options for  perspective on research p•Improve Care community re‐integration Delivery  Increase connections with Unique challenges for  Unique challenges for Primary care Primary care specific populations of care System•Reduce Cost Need for community Need to create systems perspective on care navigation•Create Jobs Community services need  Hospitals,  p , Expanding Caregiver Expanding Caregiver Pilots  to focus on recovery  and  medical issues Providers,  Expand wellness programs – e.g. Fit for Function Increase access to  Care  Care rehab for acute chronic conditions Need for strategic Collaborations/partnerships Networks Lack of awareness of  Community programs Increase need for Peer  support – survivor groups Need to focus on transitions Need to collaborate with other strategies – i.e. COPD,  other strategies i e COPD Importance of timeliness Diabetes, cardiovascular of treatment Increase partnerships with case management Coordinated Pediatric Care
  • 26. 1st1t2nd 26
  • 27. 27
  • 28. 2nd Curve: an IHI View 28
  • 29. High Reliability in Medicine: Where Do You Need to Be? Future Performance (Second Curve/ 6+ Si Sigma) ) First Curve/ 4 sigma (Craft+Information- mance  Age Culture )  (Craft-AgePerform (Bifurcation  Culture) curve: 2000s) P Flexner 1910 Time             - 29
  • 30. Columns 2 & 3 = 2nd Curve Columns 2+3 = 2nd Curve Regulation Medical Science Management Hammurabi Hippocrates Science   Industrial Legal system Nightingale, 4 doctors Revolution    State Boards Flexner, Codman, Flexner Codman Taylor: “Scientific Scientific  ACS/Hospital Management”  Standardization  JCAHO  Shewhart “Inspection” Inspection M&M conferences    Deming, Juran,  Donabedian,structure Total QualityFed/State regs process, outcome    Complexity theoryORYX, EMTALA, Outcomes, Disease  HIPAA, Etc. management   Lean, Action   Learning, AppreciativeJC, CMS “core Evidence based Inquiry, Adaptive Design, High Reliability, measures,” care, Hospitalists Resilience HCAHPS 30
  • 31. 2 Historical Curves of Health Care Innovation (derived from Kuhn, Toffler, Morrison, Merry) Future Performance (Second Curve/ 6+ Si Sigma) ) First Curve/ 4 sigma Resilience, (Transfer/Sustain mance  2010 Human Momentum)  (Create and Perform (Bifurcation Factors, Factors 2000  Build curve: 2012)  TQM, 1990  Momentum) P Circa 1910 Time             - 31
  • 32. Leading for ChangeBucket 1: Optimizing the  Bucket 2: Preparing to  Bucket 3: Moving Up the First Curve Move Up the Second  Second Curve and  Curve Distinguishing Yourself in  g g the New Landscape of  Healthcare• Focus on data • Widen the lens: focus on both  • Use information with • Emphasize problem‐solving E h i bl l i qualitative and quantitative  lit ti d tit ti situational awareness, creating  it ti l ti• Root cause analysis information  contextual knowledge• More effective execution of  • Precede problem‐solving with • Combine problem‐solving and  established methods (i.e. for  problem‐finding problem‐finding with problem‐ preventing central line  • Reach out: more information,  framing and situational  infections) wider network, more resilient  deployment (cf. Kim Cameron, FAA) • Add positive deviation, success  • Add appreciative inquiry story analysis, and action  • A shift of assumptions on the  learning/ ongoing  design criteria for care systems  design criteria for care systems experimentation and what performance levels  are possible and necessary  (e.g. from % to Sigma thinking)
  • 33. Buckets 1 & 2: Central Line Infections• Bucket 1: Moving from the assumption of “a a minimal number of inevitable infections that are inherent in the procedure by just applying procedure” known preventive measures more rigorously• Bucket 2: Achieving 0 infections and in so infections, doing, changing our assumptions about achievable performance
  • 34. The Policy Environment: Affordable Care Act• New insurance rules guaranteeing coverage• High risk High-risk pool for people with pre existing conditions pre-existing• Protection for children with pre-existing conditions• Coverage for young adults, to age 26• Small b i S ll business tax credits t dit• Preventive care, free for proven services• Early retirees temporary reinsurance• “Doughnut hole” rebates for Medicare• Annual review of premium increases• Access to care: $ Billions for Community Health Centers and the National Health Service Corps for low-income and uninsured• New incentives for providers (ACOs, CMS rewards and penalties, shared gain provisions) 34