Moving up the curve: Second curve strategies for change
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This document discusses strategies for healthcare organizations to move from optimizing their current performance to achieving higher levels of reliability and performance associated with the "second curve." The first section outlines two historical curves of innovation in healthcare - the first focusing on standards and best practices, and the second involving new management approaches to achieve reliability levels of 6 sigma or higher. The rest of the document then discusses three "buckets" or levels that healthcare organizations can progress through: 1) optimizing current performance, 2) preparing to improve by addressing cultural and structural barriers, and 3) distinguishing themselves through new collaborative and system-wide approaches that transcend traditional silos. Key aspects of each bucket are outlined.
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Moving up the curve: Second curve strategies for change
- 1. Moving Up Healthcareâs Second Curve: Strategies for Change IE 6 11/6/2012
- 2. 1st 1t 2nd 2
- 3. 3
- 5. High Reliability in Medicine: Where Do You Need to Be? Future Performance (Second Curve/ 6+ Si Sigma)ď¸ )ď¸ First Curve/ 4 sigma (Craft+Information- mance ďą Age Culture ) ďą (Craft-Age Perform (Bifurcation ďą Culture) curve: 2000s) ďą P Flexner 1910 Time ď° ď° ď° ď° ď° ď° ď° ď° ď° ď° ď° ď° - 5
- 6. Columns 2 & 3 = 2nd Curve Columns 2+3 = 2nd Curve Regulation Medical Science Management Hammurabi Hippocrates Science ď˛ ď˛ Industrial Legal system Nightingale, 4 doctors Revolution ď˛ ď˛ ď˛ State Boards Flexner, Codman, Flexner Codman Taylor: âScientific Scientific ď˛ ACS/Hospital Managementâ ď˛ Standardization ď˛ JCAHO ďŻď˛ Shewhart âInspectionâ Inspection M&M conferences ď˛ ď˛ ď˛ Deming, Juran, ď˛ Donabedian,structure Total Quality Fed/State regs process, outcome ď˛ ď˛ ď˛ Complexity theory ORYX, EMTALA, Outcomes, Disease ďŻď˛ HIPAA, Etc. management ď° ďŻďŻ Lean, Action ď˛ ď˛ Learning, Appreciative JC, CMS âcore Evidence based Inquiry, Adaptive Design, High Reliability, measures,â 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)ď¸ )ď¸ First Curve/ 4 sigma ďŻResilience, (Transfer/Sustain mance ďą 2010 ďŻHuman Momentum) ďą (Create and Perform (Bifurcation Factors, Factors 2000 ďą Build curve: 2012) ďŻ TQM, 1990 ďą Momentum) P Circa 1910 Time ď° ď° ď° ď° ď° ď° ď° ď° ď° ď° ď° ď° - 7
- 8. High Reliability and The Performance Curve Safety Culture Safety Operating Sigma Level Operating Level Performance Performance Margin Level Level Need Chaotic Below Average 0 None or in Awareness A deficit d fi it Reactive Normal Average 2 2% Implementing Reliable Good 4 5% Performer P f Proactive Highly Reliable High Performer 6 10% Generative Ultrasafe Standardâ 7â9 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 Model Bucket 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 ⢠Coâmanagement ⢠Triâmanagement ⢠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 ⢠Crossâ silo information ⢠Wholeâsystem Lean (Va. management: beyond Mason, Thedacare) silos; manage better the information we have
- 11. Leading for Change Bucket 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 problemâsolving 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 problemâsolving with ⢠Combine problemâsolving and established methods (i.e. for problemâfinding problemâfinding with problemâ 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 âa a minimal number of inevitable infections that are inherent in the procedure by just applying procedureâ 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 g Initial Concern Surgery Consult OR/OpenBiopsy OR/O Bi (Cycle time of process Biopsy Read built 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-solve our way to 2nd Curve High Reliability Problem Solving âAppreciative Inquiryâ Problem identified Appreciating/valuing best of âWhat isâ ď˛ ď˛ Analysis of causes Envisioning âWhat might beâ ď˛ ď˛ Possible solutions Dialoguing âWhat should be What beâ ď˛ ď˛ Action planning Innovating âWhat will beâ Assumption: Success = Assumption: Success = a problems solved possibility envisioned/created âadapted from Bernard Mohr f 15
- 16. Creating g 2 nd Curve Cultures âChanging how g g 2nd Curve Vision work is done changes the g Change Processes culture.â - 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 ⢠âDoughnut holeâ 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. âPhysician leadership is essential. Physician essential Improving the value of health care is something only medical teams can do. . . do Physicians can lead this change and return the practice of medicine to its appropriate focus: enabling health and effective care.â - Michael Porter, PhD, MBA 18
- 19. Bucket 3: 2nd Curve Structure Innovation Community Memorial Hospital Menomonee Falls, WI 19
- 20. A 1917 Design, as of 2012 Board of Trustees ďŠ Medical St ff E M di l Staff Executive ti Chief Executive Chi f E ti Committee Officer ďŞ Medical Staff Functions Hospital Functions (âSilo 1â) (âSilo 2â) ⢠Credentialing ⢠Nursing ⢠Departmental (Peer) ⢠Ancillary Specialties Review Departments ⢠Laboratory ⢠Surgical Case Review ⢠Radiology ⢠Blood UR ⢠Physiotherapy ⢠Drug Usage Review ⢠Risk Management ⢠Pharmacy andThe Structure ď° 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. âDoctor, Iâd like you to resign from this di l t ff f thi medical staff for reasons of ill f health. You make me sick.â 21
- 22. The Vision 1. 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 Care Medical Executive Senior Mgt. Team Committee Patient/ Operational Medical Staff Functions 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 Modelâ 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 â˘Improve Care community reâintegration Delivery Increase connections with Unique challenges for Unique challenges for Primary care Primary care specific populations of care System â˘Reduce Cost Need for community Need to create systems perspective on care navigation â˘Create Jobs Community services need Hospitals, p , Expanding Caregiver Expanding Caregiver Pilots to focus on recovery and  medical issues Providers, Expand wellness programs â 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 â survivor groups Need to focus on transitions Need to collaborate with other strategies â i.e. COPD, other strategies i e COPD Importance of timeliness Diabetes, cardiovascular of treatment Increase partnerships with case management Coordinated Pediatric Care
- 26. 1st 1t 2nd 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)ď¸ )ď¸ First Curve/ 4 sigma (Craft+Information- mance ďą Age Culture ) ďą (Craft-Age Perform (Bifurcation ďą Culture) curve: 2000s) ďą P Flexner 1910 Time ď° ď° ď° ď° ď° ď° ď° ď° ď° ď° ď° ď° - 29
- 30. Columns 2 & 3 = 2nd Curve Columns 2+3 = 2nd Curve Regulation Medical Science Management Hammurabi Hippocrates Science ď˛ ď˛ Industrial Legal system Nightingale, 4 doctors Revolution ď˛ ď˛ ď˛ State Boards Flexner, Codman, Flexner Codman Taylor: âScientific Scientific ď˛ ACS/Hospital Managementâ ď˛ Standardization ď˛ JCAHO ďŻď˛ Shewhart âInspectionâ Inspection M&M conferences ď˛ ď˛ ď˛ Deming, Juran, ď˛ Donabedian,structure Total Quality Fed/State regs process, outcome ď˛ ď˛ ď˛ Complexity theory ORYX, EMTALA, Outcomes, Disease ďŻď˛ HIPAA, Etc. management ď° ďŻďŻ Lean, Action ď˛ ď˛ Learning, Appreciative JC, CMS âcore Evidence based Inquiry, Adaptive Design, High Reliability, measures,â 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)ď¸ )ď¸ First Curve/ 4 sigma ďŻResilience, (Transfer/Sustain mance ďą 2010 ďŻHuman Momentum) ďą (Create and Perform (Bifurcation Factors, Factors 2000 ďą Build curve: 2012) ďŻ TQM, 1990 ďą Momentum) P Circa 1910 Time ď° ď° ď° ď° ď° ď° ď° ď° ď° ď° ď° ď° - 31
- 32. Leading for Change Bucket 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 problemâsolving 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 problemâsolving with ⢠Combine problemâsolving and established methods (i.e. for problemâfinding problemâfinding with problemâ 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 âa a minimal number of inevitable infections that are inherent in the procedure by just applying procedureâ 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 ⢠âDoughnut holeâ 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