Maureen Bisognano: An international perspective: Leading for better health care


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Maureen Bisognano, President and CEO, Institute for Healthcare Improvement, gives an international perspective on leading for better healthcare at The King's Fund Second Annual NHS leadership and Management Summit.

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Maureen Bisognano: An international perspective: Leading for better health care

  1. 1. An International Perspective:Leading for Better Healthcare 2nd Annual NHS Leadership and Management Summit 23 May 2012 The King’s Fund Maureen Bisognano President and CEO IHI
  2. 2. The Problem• In the US, we spend over $2.7 trillion per year on health care• Over 75% is spend on chronic disease management• And all of our chronic diseases are getting worse
  3. 3. The Problem• In the UK and across other countries in Europe, the same 70% of health care budgets are going to chronic disease care• Diabetes, cardiac disease, and obesity are expected to increase by 50% by 2035• The “burden of the illness” in these diseases is 24/7 and requires a new way to look at the “burden of the treatment,” including designs and costs
  4. 4. Obesity Trends* Among U.S. Adults BRFSS, 2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%Source: Behavioral Risk Factor Surveillance System, CDC.
  5. 5. Not Just an American Problem
  6. 6. Health Care Spenders and Costs The top 1% of spenders accounts for 21.8% of the costs The next 4% account for 28.2% of the costs The bottom 50% account for just 3% of the costs Spenders CostsSource: AHRQ – “The Concentration and Persistence in the Level of Health Expenditures overTime: Estimates for the U.S. Population, 2008-2009”
  7. 7. Courtesy of the Institute for Healthcare Improvement, April 2009
  8. 8. Courtesy of the Institute for Healthcare Improvement, April 2009
  9. 9. Michael Porter’s Thinking• Disutility of a primary care model with an incredibly diverse patient mix• Challenges of managing excellent clinical care with the latest evidence in the face of heterogeneity• Chaos of daily life for clinicians
  10. 10. Joanne Lynn’s Thinking • “Bridges to Health Model” ─Splits populations into 8 segments 1. Healthy 2. Maternal-infant health 3. Acutely ill, likely to return to health 4. Chronic conditions with normal daily function 5. Serious relatively stable disability 6. Short decline to death 7. Repeated exacerbations, organ system failure 8. Multi-factor frailty, with or without dementiaLynn, Joanne, Straube, Barry M., Bell, Karen M., Jencks, Stephen F. andKambic, Robert T., Using Population Segmentation to Provide Better HealthCare for All: The Bridges to Health Model. Milbank Quarterly, Vol. 85, No. 2,pp. 185-208, June 2007.
  11. 11. Where Are We? Optimizing the Current Model Technical Leadership: • Problem solving through expertiseViability Transforming the Organization Adaptive Leadership • New beliefs & behaviors • New relationships Patient • New customers Inflection Point Clinical Model Episodic Care  Coordinated Care  Population Directed Care Adaptive Challenge Business Model Fee for Service  Bundled Payment/Capitation  Disruptive Innovation? Technical Infrastructure Segmented  Integrated  Cloud Leadership Models Adapted from The Second Curve, Ian Morrison 1996
  12. 12. Build widespread improvement capability − Leadership − Middle management − Front-line teams − Integrated clinical teams − Engaged, empowered, and enthusiastic staff Work on Safety − Reduce medical errors and harmThriving − − Eliminate “never events” Work on preventable admissionson the and readmissionsFirst Curve Engage members/patients and families − Ensure access − Design for continuous care − Improve patient engagement and satisfaction Improve efficiency − Reduce artificial variation (LOS, use rates, readmissions, etc.) − Eliminate “flow faults” − Set a goal of reducing waste by 1-3% of operating expense budget for I year, year on year
  13. 13. Henry Ford Health System Total Harm-Associated Costs 2009* Harm Issue Total Associated Costs Pressure Ulcer stage 2 or higher $10,624,410 Coded Procedural Complication ICD9 (998-999.99) $7,670,520 UTI using coded data and AHRQ definition. $5,662,895 Glucose below 40 $3,846,375 Coded Acute Renal failure $2,665,680 Coded DVT/PE in both medical and surgical patients $2,365,470 No Pulse Blue Alert $1,535,808 Coded Medication issue $1,216,078 Clostridium difficile infection $824,544 Reported Fall with injury $696,527 Bloodstream Infections using NHSN criteria $640,000 Coded Pneumothorax using AHRQ definition $340,260 SSI using NHSN criteria $280,000 VAP using NHSN criteria $190,352*Henry Ford Hospital Only
  14. 14. What Improvement Skills are Needed for Each Role? Everyone Change Agents Operational (Middle Leaders Experts (Staff, (Executives) Managers, Supervisors, Stewards, UBT lead project leads) triad) • Analysis, prioritization of portfolios • Setting direction and big goals • Deep statistical process control • Execution leadership • Deep improvement • Portfolio selection and • Setting goals and methods • Setting goals and measures management measures • Leadership team • Identifying problems • Managing oversight of • Identifying advisory re portfolio • Mapping process improvement problems selection, process • Sequencing tests of change • Being a champion and • Mapping process • Effective plans for • Simple understanding sponsor • Testing change implementation and variation • Understanding variation spread • Simple waste to lead reduction • Implementation and spread • Simple waste reduction • Managing • Simple implementation and standardization • Simple standardization spread • Team behaviors 16
  15. 15. Wave III focuses on full deployment and execution and IV on expansion and continuous improvement Waves of Improvement Institute February 2008 September 2008 June 2009 • 7 regions* Deepen improvement knowledge • 150 Improvement Advisors Expand Improvement system to • 5 regions (medical center, regional, national) Develop and Test the System • 80 Improvement Advisors (Medical Center) • 12 Faculty Mentors (KP) • 3 Regions • 11 Faculty Mentors (KP) • 1000+ Operations • 6 Improvement Advisors • 4 Regional mentor students managers (Medical Center) • 300 operations managers • 10,000 Front line RIM+ at a Facility level within facilities • 3 Faculty Mentors • 3,500 Front line RIM+ staff staff (internal and external) • Middle manager PSU • Middle manager PSU all facilities • Front line staff RIM • Reliable design • Reliable design • Middle managers PSU • Reliable design Learning and sharing systems regionally and program-wide Improvement InstituteLevel of Project Difficulty Continuous Complete On-boarding Implementation Expansion Improvement We are here 17
  16. 16. Leadership and capability − Build innovation capability and set aims − Analyze key areas for design (population segments, geographic areas) − Identifying “light green potential” & translating to “dark green dollars” Work on spreadThriving − Ensure best practices and results everywhereon theSecond New partnershipsCurve − Payer “deep dive” such as “marketplace collaboratives” − Build on ABCD or community organizing skills New designs − Coordinated care for frail, older population − Triple Aim designs for the sickest − The “year of care” for the well 50%
  17. 17. Organizations Learning from PatientsThe Old Way• Ryhov Hospital in Jönköping had traditional hemodialysis and peritoneal dialysis center.• But in 2005, a patient, Christian, asked about doing it himself.
  18. 18. The New Way• Christian taught a 73-yr-old woman how to do it…• …and they started to teach others how to do it.
  19. 19. The New Way• Now they aim to have 75% of patients to be on self-dialysis• They currently have 60% of patients
  20. 20. Lessons to Date• From Christian (patient): ─“I have a new definition of health.” ─“I want to live a full life. I have more energy and am complete.” ─“I learned and I taught the person next to me, and next to her. The oldest patient on self- dialysis is 83 years old.” ─“Of course the care is safer in my hands.”
  21. 21. Lessons to Date• From Anette (nurse leader): ─ Surprised at design differences between patients, family, and staff ─ Managing at 1/2 – 1/3 less cost per patient ─ Evidence of better outcomes, lower costs, far fewer complications and infections ─ “We brought in the county’s employment, helped the patients make or update the CVs, and trained them for a new career.”
  22. 22. Update• Now calculated costs at 50% of costs in other hemo-dialysis units• Complications dramatically reduced and subsequent expensive care avoided• Measuring success by “number of patients working”
  23. 23. Jonkoping Visit, October 2011
  24. 24. PFCC
  25. 25. Tony DiGioia Dr. Anthony M. DiGioia III, orthopedic surgeon and developer of the patient- andfamily-centered care program for UPMC, in his office at Magee-Womens Hospital in Oakland.
  26. 26. Wellness Focus
  27. 27. 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.
  28. 28. 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.
  29. 29. 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.
  30. 30. Study Tour in Denmark
  31. 31. Leadership − Redesigning the workplace to optimize teamwork − Engage the community (ABCD and organizing)Thrivingon the Optimize health and care skills with the community − Shared decision makingThird Curve − Move from “What’s the matter?” to “What matters to you?” − Real goal-setting Innovate for technology integration − Optimize the use of technology, the patients’ perspective and use of data, and other technologies
  32. 32. Health of a PopulationExperience of Per Capita Care Cost
  33. 33. IHI’s Partners/Activation Mechanisms: Memphis / Shelby County, TN• Memphis Activation Mechanism: ─ A virtual faith-based network.• Focus of Activation mechanism – Project Goals: 1. Reduce untreated and unmanaged hypertension among low-income African American men 2. Reduce health risk and incidence of uncontrolled chronic disease for vulnerable women in Memphis
  34. 34. Activating Memphis’Congregational Health Network (CHN)• Scaling up the reach to young women: ─ Beginning with 30 existing CHN members in Year 1 and scaling up engagement to over 2,000 designated health volunteers in approx. 300 churches over 3 years.  Reaching over 8,000 women across the community with information and skills for self-care and health improvement through family and community networks.• Scaling up the reach to men: ─ Onsite screening for hypertension and other health risks will be carried out at approx. 400 congregations over the first two years (150 in Year 1 and 250 in Year 2).  Paired with additional outreach in Year 3 through male church members’ connections to other community groups, including workplaces, neighborhood associations, and social groups, these efforts are expected to reach approx. over 2,700 individuals with previously undiagnosed or untreated hypertension who can be brought into community-based treatment.
  35. 35. Malawi Progress• Population ~13 million• Maternal mortality: ~350/100,000 (USA <10/100,000)• Neonatal Mortality: ~30/1000 ( in the US ~4/1000) 3 Districts • Aim: Reduce maternal and neonatal mortality by 30% in three Districts (pop 3 million) by February 2012. • 5-year RCT to test health facility (QI), and community interventions (women’s groups) Partners: Women and Children First, Inst Child Health UCL, IHI. Funders: The Health Foundation.
  36. 36. Focus of our Interventions3 Delays model• Delay in deciding to seek care• Delay in reaching the Women Groups & Task facility Forces• Delay in receiving timely QI intervention and appropriate care PLAN SMALL TEST ACT CYCLES THAT DO TAP LOCAL KNOWLEGE STUDY
  37. 37. Focus on Demand, Supply and Linkages Referral & Access Increasing Demand Quality services
  38. 38. Malawi: Results Over 4 YearsInfrastructure for change• Established new NGO – MaiKhanda• Community structures: 650 Women’s groups• Facility structures: 55 QI teams formed (13 hospitals, 42 health centers)• Linkage structures: 707 safe motherhood task forcesRCT evaluation results show:• 22% reduction in NMR for combined FI and CI intervention (no effect for either intervention alone)• 16% reduction in perinatal mortality for CI alone, no effect of FI alone• No reduction of MMR over secular trends
  39. 39. Southcentral Foundation Anchorage, Alaska • “Nuka” – Alaskan word for strong, giant structures and living things. ─ Also the name for the health care model that transformed the system from health care transactions for patients to a healthy system with the population
  40. 40. Some Programs (Relationships) Elder Program • Healthy Elders through supportive gathering, activities, sharing, caring - relationships Pathway Home • Recovering youth through development of community, healthy relationships, personal and group responsibility RAISE • Youth internships emphasizing team, group, learning, responsibility, skills – within SCF Nuka System of Care (relationships) Dena-A-Coy • Residential treatment for pregnant women to return to healthy relationship with self, family, pregnancy, newborn infant.
  41. 41. Some Programs (Relationships) Nutaqsiivik • Two year partnering in intensive personal relationship between SCF staff and new mothers with infants Quyana Clubhouse • Long term personal relationships with individuals with limited cognitive capabilities and mental health challenges to support healthy living Primary Care • Complete rethinking of what our roles are – everyone – in the integrated care team environment where trusting, accountable, long-term, personal relationships are the core service delivered – with full same-day access – and the whole person and family are supported.
  42. 42. Why listen to our story Evidenced-based generational change reducing family violence 50% drop in Urgent Care and ER utilization 53% drop in Hospital Admissions 65% drop in specialist utilization 20% drop in primary care utilization 75-90%ile on most HEDIS outcomes and quality Childhood immunization rate of 93% Over 50% of Diabetics with HbA1c below 7% Employee Turnover rate less than 12% annualized (very low) Customer and staff overall satisfaction over 90% In an urban Alaska Native community with huge challenges Sustained for over a decade and continually improving Very long list of external recognitions – Baldrige Award now
  43. 43. Per Capita ExpendituresCopyright © 2011 Southcentral Foundation. All Rights Reserved.
  44. 44. Looking Ahead• New definitions of “organization”• New ways to lead multigenerational work forces• New methods and a new culture of engaging patients and families in designs• New learning networks for all of us