Taking Transformational Change To Scale.Doebbeling.3.9.10.Final

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Taking transformational change to scale: Reducing MRSA and other infections.
5th National Pay for Performance Summit:
Mini Summit IV: Tools and Strategies to Support Transformational Change
San Francisco, CA, March 8-10, 2010

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  • Collaborative unique nationally as an opportunity to learn from electronically and culturally interconnected system of hospitals (INPC) and international consortiumReduced rates of up to 60-85% in Pittsburgh VA, RWJ Sites, and our phase 1 using similar methods
  • Site 3 had a tool focused on coordination of care between primary and specialty careSite 2 had much on paper-electronic blend—had greatest use of paperSite 4 (PH) had more comments about functionality—was that related to positive or negative comments—comparable in advanced IT development to VA, but smaller system—huge IT research dept colocated with themUsability comments comparable across the sites similar even though very different systems—most were negativeLowest site on usability (RI) had templates, fewest negative commetns on usability probably related to using less for their jobRigidity—computer system, electronic medical record—forced you to do things, computer systemSite 1 and 3 had highest comments about rigidity (VA’s) and centrally controlled development strategyCoordination between specialty and primary care—tool developed as joint effort between primary and specialty care to foster scheduling, intake and provider and specialty and provider. Here coordination between intake and provider removed.Make a list of interpretations—do this again after we create figure from card sort and recommendations.
  • Combining Lean Techniques (Lean) and Positive Deviance (PD) strategiesLean historically used in manufacturing industry, but increasingly used with much success in healthcarePositive Deviance (PD) recognizes that the experts are within an organization Opportunity to learn- challenges and synergies in combining approaches
  • Reveals communicative patterns of complex groups and teams Identifies the strength and frequency of the connections between members (e.g., with whom and how often do you communicate about reducing MRSA)Describes the current social network for work in general and the MRSA Bundle implementation in particular
  • Future, All
  • Reduction in MRSA isolates in an ICU Literature Cost Savings (avoidance) per Infection: $ 6,916.00 - $35,000Active Surveillance Cost & Precautions max 10% of infection cost at $ 610 per patientMethods challengingWe want to work with you (and CFOs) in capturing these data in meaningful way informed by your institutional perspectives
  • Staff Satisfaction- that they can actively prevent disease, morbidity, and mortalityStaff Satisfaction- that they are national leaders in a clinical activity at the HEART of nursing (Nightingale)
  • Taking Transformational Change To Scale.Doebbeling.3.9.10.Final

    1. 1. Taking transformational change to scale:Reducing MRSA and other infections<br />5th National Pay for Performance Summit:<br />Mini Summit IV: Tools and Strategies to Support Transformational Change<br />San Francisco, CA, March 8-10, 2010<br />Brad Doebbeling, MD, MSc<br />Professor of Medicine, Epidemiology, & Biomedical Engineering, Indiana University School of Medicine <br />Senior Scientist, IU Center for Health Services Research, Indianapolis VA COE, Regenstrief Institute,<br />Indianapolis<br />Award Number: HHSA290200600013I, Task Order No. 4<br />
    2. 2. Acknowledgements<br /><ul><li>Funding from AHRQ
    3. 3. Testing Techniques to Radically Reduce Antibiotic Resistant Bacteria HHSA2902006000131 (Completed)
    4. 4. Healthcare Associated Infections (HAI) Initiative Assessment Program HHSA290200600013I (Current)
    5. 5. Implementing and Improving the Integration of Decision Support into Outpatient Clinical WorkflowHSA2902006000131(Current)
    6. 6. Funding from AHRQ and CDC
    7. 7. Testing Spread and Implementation of Novel MRSA-Reducing Practices HHSA290200600013 (Current)
    8. 8. Thanks to our collaborators, partners, providers, patients!</li></li></ul><li>Capacity for Impact<br />High priority project to avert illness, suffering, and death<br /><ul><li>Unique International Collaborative
    9. 9. Learning community of practice (7 hospitals)
    10. 10. Electronically and culturally interconnected
    11. 11. International consortium
    12. 12. Effectiveness -- Reduced rates 60-85%
    13. 13. Pittsburgh VA
    14. 14. RWJ Sites
    15. 15. Phase 1 Indy</li></li></ul><li>Framework<br />
    16. 16. Panarchy or Ecocycle Model of Change<br />Maturity<br />Renewal<br />Creative Destruction<br />Birth<br />For more information on the ecocyle go to http://www.plexusinstitute.org/edgeware/archive/think/main_aides9.html<br />
    17. 17. Institutional level<br />A change in culture A change in laws A change in resource distribution/availability<br />Organizational level<br />A change in strategiesA change in procedures A change in resource distribution/availability<br />Network or group level<br />A change in conversation A change in routine A change in resource commitment or influence <br />Individual level<br />A change of heart A change of habits A change of ambition<br />“Getting To Maybe: How the World is Changed”<br />Frances Westley, Brenda Zimmerman, Michael Patton, 1996, Random House Canada<br />
    18. 18. Socio-technical Systems Framework<br />Social Subsystem<br /><ul><li> Key stakeholder views
    19. 19. Patient barriers/facilitators
    20. 20. Organizational buy-in
    21. 21. Leadership support
    22. 22. Training
    23. 23. Unintended social consequences</li></ul>Technical Subsystem<br /><ul><li> Usability
    24. 24. Functionality/scope
    25. 25. Computer/IT support
    26. 26. Flexibility in IT tools
    27. 27. Iterative design
    28. 28. Unintended technical consequences </li></ul>Joint Optimization<br /><ul><li> Integration of CDS - for CRC screening - into clinical workflow</li></ul>External Subsystem (Context)<br /><ul><li>PERFORMANCE MEASUREMENT
    29. 29. Workload
    30. 30. Financial factors
    31. 31. Unintended external consequences</li></ul>Westbrook et al., JAMIA, 2007; Harrison et al., JAMIA 2007<br />
    32. 32. Strategy<br />
    33. 33. Tranformative Change: 7 Effective Strategies<br />Fostering Change<br />Communication & Collaboratives<br />Local, Focused Implementation <br />Frontline Staff Engagement<br />Organizational Learning <br />Support, Resources & Accountability<br />Feedback & Reinforcement<br />Qualitative Thematic Analysis, Healthcare Associated Infections (HAI) Initiative Assessment Program , AHRQ ACTION, HHSA290200600013I , 2010<br />
    34. 34. “Collaboration” – What does it mean?<br />“Coming together is a beginning. Keeping together is progress. Working together is success.” – Henry Ford.<br />“Teamwork divides the task and multiplies the success.” - Unknown<br />“Teamwork is the ability to work together toward a common vision; the ability to direct individual accomplishment toward organizational objectives. It is the fuel that allows common people to attain uncommon results.” – Andrew Carnegie<br />
    35. 35. An Operational Citywide Electronic Infection Control Network<br /><ul><li>Infection control a regional problem, requiring coordinated effort
    36. 36. Created citywide electronic notification system to prospectively track all known patients with MRSA
    37. 37. Track over 17,000 patients with a h/o MRSA infection or colonization across Indianapolis.
    38. 38. Delivered 2698 admission alerts on patients with a history of MRSA, 19% from another institution.
    39. 39. 20 infection control providers (ICPs) spanning 16 hospitals </li></ul>Kho, Lemmon, Dexter, Doebbeling AMIA 2008<br />
    40. 40. % of Coded Segments in the Technical Sub-Section by Themes & Sites<br />12<br />Implementing and Improving the Integration of Decision Support into Outpatient Clinical Workflow, AHRQ ACTION HSA2902006000131<br />
    41. 41. Unique Strategy for Sustained Organizational Change<br />Combining Lean and Positive Deviance<br />Lean from manufacturing<br />Major QI Approach in Healthcare<br />Positive Deviance (PD)<br />Experts within organization<br />Opportunity to learn & innovate- <br />Challenges and synergies<br />
    42. 42. MRSA Phase Two<br /><ul><li>What is Positive Deviance?
    43. 43. Technique to engage front line staff in owning & improving processes and sustaining change
    44. 44. Based on identification of practices of used by ‘positively deviant’ staff/departments
    45. 45. Critical for staff involvement/buy-in</li></li></ul><li>Integrated Lean/PD approach<br />Define the Problem<br />Baseline Current Processes<br />Discovery<br />Identify <br />Operational Barriers<br />Develop<br />Future State Process<br />Action<br />Process Control<br />Strategy<br />
    46. 46. Creative Kickoffs<br />Multiple kickoff meetings to maximize participation<br />Very serious and very fun<br />
    47. 47. Staff Engagement<br />
    48. 48. Partnership Meetings<br />Monthly meetings with volunteers<br />D&A’s<br />Brainstorm solutions<br />Discuss ideas<br />
    49. 49. One Is Too ManyDiverse Core & Resource Groups<br />ICP manager<br />Director of Quality<br />Nurse educators from two intervention units<br />Lean expert<br />OD expert<br />Nurse project coordinator<br /><ul><li>VP Nursing
    50. 50. C00
    51. 51. ID MD
    52. 52. System office grant manager (ACT project)
    53. 53. Two coaches from Plexus</li></li></ul><li>Discovery and Action Dialogues <br />Goal to ‘discover’ the issues and potential solutions, then take ‘action’ ASAP.<br />Informal meetings with front line staff to discuss current status of the process.<br />Incorporate as many front line staff as possible.<br />It is easier to “act your way into a new way of thinking”than to “think your way into a new way to acting”<br />
    54. 54. Discovery & Action Dialogues<br />Seven facilitators trained in the first month<br />Jumped in the deep water with 20 minutes of training<br />
    55. 55. Transmission Disaster Response Teams<br />Transmission Disaster Response Teams<br />D&ADs dialogues and leader rounds linked with specific transmission cases to build collective mindfulness within and across units.<br />
    56. 56. Sharing Results<br />Community briefing<br />Making sense of maps on the units<br />Clinical leaders<br />Admin leaders<br />Where am I? Is our network smarter than MRSA?<br />
    57. 57. Social Network Mapping + Culture Survey<br />Dreaming up & researching questions<br />Social networking software<br />Creating a “family of measures”<br />
    58. 58. Social Network Analysis<br />Reveals communicative patterns of complex groups and teams <br />Identifies the strength and frequency of connections (e.g., with whom and how often do you communicate about reducing MRSA)<br />Describes current network in general & MRSA Bundle implementation in particular <br />
    59. 59. Whom would you like to include or see involved in future MRSA prevention work?<br />
    60. 60. Organizational Benefits of Change<br />Staff developed skills and processes<br />Documented, standardized processes <br />Isolation signs and chart stickers<br />Documented protocols for Active Surveillance & Prevention<br />Patient, family and staff education materials and methods<br />
    61. 61. Partnering in Data Collection, Analysis, Reporting<br />Document impact in standardized language<br />Characterize efforts and strategies that work and disseminate nationally<br />Engagement of teams & coaches planning and conducting<br />Dissemination strategies- capturing stories, social networks, engagement, outcomes<br />
    62. 62. Document ROI Impact<br />Reduction in MRSA isolates in an ICU<br /> Literature Cost Savings (per Infection): <br /> $ 6,916 - $35,000<br />Active Surveillance & Precautions Cost:<br />Max $ 610 per infected patient (10%)<br />Methods challenging<br />Working with teams (& CFOs) to capture these data in meaningful way<br />Source: The Impact of Methicillin Resistance in Staphylococcus AureusBacteremia on Patient Outcomes: Mortality, Length of Stay, and Hospital Charges, Cosgrove, et al, February 2003<br />
    63. 63. Vision for Data Services – R&D Needed<br /><ul><li>Increased use of Electronic Data
    64. 64. Less effort on Surveillance
    65. 65. Maximize return on surveillance efforts
    66. 66. More effort on active Intervention
    67. 67. Results Oriented
    68. 68. Actionable Information & Value-added services
    69. 69. Standardized, Accurate Measurement
    70. 70. Optimized Outcomes- Clinical & Financial</li></li></ul><li>Conclusions<br />Start small, build on success.<br />Organizational change & sustainability strategies needed.<br />Change initiatives need both top-down support and bottom-up engagement.<br />Collaboratives foster teamwork!<br />Resource and data intensive.<br />Enthusiasm builds from within because redesign teams own it!<br />Informatics tools helpful –needs R&D<br />
    71. 71. •<br />“Collaboration” – What does it mean?<br />“Alone we can do so little; together we can do so much.” – Helen Keller<br />“Strength is derived from unity. The range of our collective vision is far greater when individual insights become one.” – Andrew Carnegie<br />“Collaboration equals innovation.” - Michael Dell<br />
    72. 72. Thank You!<br />Questions? <br />Contact<br />Brad Doebbeling<br />bdoebbel@iupui.edu<br />bdoebbeling@gmail.com <br />

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