2014 beardmore lecture derek feeley executive vice president institute for healthcare improvement...
TRANSCRIPT
2014 Beardmore Lecture
Derek FeeleyExecutive Vice President Institute for Healthcare Improvement
November 2014
Gail, insert updated IHI Strategy on a page
A view from over the pond
Scotland is one of the leading health care systems in the world!
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Commonwealth Fund Study4
Imagine a land where….
A patients’ charter of rights and responsibilities is in place that
includes waiting time guarantees.
Over 90% of patients requiring elective care are treated within 18
weeks.
Over 98% of in-patient procedures and day-surgery cases are treated within 12 weeks of agreement to
treat.
Over 90% of patients are seen within four hours in the emergency
department.
Citizens can access the most appropriate member of their
primary care team within 48 hours.
Up-to-date statistics and reports on wait times and health system
performance indicators are publicly available.
Fortunately, this land already exists
Share of hospital costs accounted for by administration
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United States; 25.3%
Netherlands; 19.8%
England; 15.5%
Wales; 14.3%
Canada; 12.4%
Scotland; 11.6%
Himmelstein et al, Health Affairs, September 2014
“Among the UK nations, Scotland’s administrative costs were lowest, England’s were highest and Wales’ were in between. This ranking correlates roughly with the role of market mechanisms in those nations’ health care systems.”
Ground-breaking
Ground-breaking
However. . . .
• Politics• Economics• Demographics• Epidemiology• Social determinants of health• Changing expectations• Workforce
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We need a sustainable method11
So, what’s the plan? 12
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Click icon to add picture
It can’t be like this, either. . . . .The Choluteca Bridge, after Hurricane Mitch
All improvement is change (but not all change is improvement)
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Change is inevitable
(Except from vending machines)
5 keys to thrive in a changing world
• Constancy of purpose• Compassionate governance• Stay true to your values (especially in the
toughest times)• Change how you lead• Share your power
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Constancy of purpose
• Keep Quality as the business strategy
• Find the joy in work• A human face behind
every statistic
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Quality as a Business Strategy
1. Establish and communicate the purpose
2. View the organization as a system
3. Get the right information for improvement
4. Integrate with business planning
5. Manage improvement activities
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A strategy and a roadmap18
Welcome to IHI19
Joy
Gratitude
Hope
Awareness of abundance
Deep satisfaction from serving others
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Burnout affects patients
More mistakes
Less adherence to physician advice
Less sympathy
Less patient satisfaction
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Beverly S.2/4/09
Med Error
Dorothy R.1/28/09
Delay In Treatment
Sharenda W.2/15/09
Med Error
Edward R.4/23/09
Wrong Side Procedure
Robert D.5/12/09
Post Procedure Death
Donna S.6/4/09
Retained foreign object
47% Reduction SSER from Dec. 08 Baseline48% Reduction in # of events year to year
24 Patients & Events – Jan-Dec,2009 vs 46 Total for 2008
47% Reduction SSER from Dec. 08 Baseline48% Reduction in # of events year to year
24 Patients & Events – Jan-Dec,2009 vs 46 Total for 2008
Lilliam C.4/3/09
Retained foreign object
Juanita A.5/14/09
Delay In Treatment
Yoland C.7/7/09
Delay in Treatment
Michael F.8/20/09
Retained foreign object
Peggy P.7/1/09Burn
Loueene D.9/23/09
Fall
Karen C.9/28/09
Delay In Treatment
Brenda R.10/14/09
Delay In Treatment
James H.10/25/09
Post Procedure Death
Monroe K.5/18/09
Post Procedure Death
Alma M.11/6/09
Fall
Johnny B.11/9/09
Fall
Jerry Y.11/7/09
Fall
Willie B.11/5/09
Med Error
Pauline M.11/2/09
Fall
Ronnie D.11/3/09
Delay in Treatment
Scott G.9/5/09
Delay in Treatment
Helen C.11/4/09
Delay In Treatment
Statistics are people with the tears wiped away
Don Berwick25
“The source of energy at work is not in control, it is in connection to purpose.”
Compassionate governance
• Learning, not judgment • Joy, not fear• An arm around the
shoulder, not a ‘head on a plate’
• Bright spots not just defects
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System Psychology
Knowledge Variation
• Complex adaptive systems• Multidisplinary teams• Social network theory
• Reliability theory
• Program evaluation• Operational definitions
• Model for improvement• Design of experiments
• Decision theory• Leadership• Diffusion of innovations• Theories of motivation
• Measurement• Regression• Graphical displays of data• Statistical process control
A little too soft for you?
Deming to the rescue!
“The First Law of Improvement”
Every system is perfectly designed to achieve exactly
the results it gets.
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The simple, wrong answer
Blame somebody!
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The Problem
Better Quality Worse
Frequency
Answer #2 – Bad Apples
The Cycle of Fear 31
Increase Fear
Kill the Messenger
Filter the Information
Micromanage
Mid Staffs coding of palliative care vs HSMR
2004
-Q2
2004
-Q4
2005
-Q2
2005
-Q4
2006
-Q2
2006
-Q4
2007
-Q2
2007
-Q4
2008
-Q2
2008
-Q4
2009
-Q2
2009
-Q4
2010
-Q2
2010
-Q4
2011
-Q2
2011
-Q40%
5%
10%
15%
20%
25%
30%
35%
40%
0
20
40
60
80
100
120
140
160
England % deaths coded as palliative care
Mid Staffordshire NHS Foundation Trust (RJD) % deaths coded as palliative care
HSMR Mid Staffordshire NHS Foundation Trust
% d
eath
s co
ded
as p
allia
tive
care
HSM
R
Some Basic Premises
1. Most people are trying hard most of the time to do a job they can be proud of.
2. All improvement is change (though not all change is improvement).
3. Fear is an enemy of improvement.
4. You feel like this now……
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QualityBetter
Old Way(Quality Assurance)
QualityBetter Worse
New Way(Quality Improvement)
Action taken on all occurrences
Reject defectives
Another way?
Source: Robert Lloyd, Ph.D.
Requirement,Specification or Target
No action taken here
Worse
Bright spots: Vietnamese children and Jerry Sternin
• Prior to 1990, Vietnam had one of the worst levels of malnutrition in the world
• How do you motivate a nation to improve outcomes?
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Bright spots
• In 1990, Jerry Sternin was asked to open an office for Save the Children in Vietnam.
• With a $50k budget, he was tasked with fixing malnutrition for children across the country.
• He started with 1 village.• Sternin recruited mothers who were ‘motivated.’ • Identified bright spots among the malnournished.
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Source; Dan Health; Switch 2010
The bright spots: what was different?
• Norms among malnourished
• Fed children twice a day
• Let children feed themselves
• Principal staple was rice
• Sweet-potato greens associated with a stigma of being poor
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Source; Dan Health; Switch 2010
• Bright spots• Fed children four times a
day• Actively fed children by
spoon if needed• Added shrimp, crabs, and
sweet-potato greens to the meal
Bright Spots- Vietnam
• The start- 4 mothers as Bright Spots• Spread to 50 malnourished families with mother’s in
groups of 10 getting together to cook meals and feed kids
• Six months later 65% of kids nourishment status improved
• Spread to 14 Villages• Reached 265 villages and 2.2 million Vietnamese
people
Source: Dan Heath ; Switch 2010
Stay true to your values
• Especially when times are tough• Person-centered in word and deed• Never ‘walk past’
Truly person-centered
Don’t walk past
Don’t walk past
Change how you lead
• You will be wrong• The leader as sense-maker• Comfortable with complexity and generous with power
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You will be wrong44
Interdependent dimensions of High-Impact Leadership
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High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.
High-Impact Leadership BehaviorsWhat leaders do to make a difference
High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.
High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.
IHI High-Impact Leadership Framework
Assets vs. Deficits48
Assets Thinking:
Strengths based
How can we create community spirit?
What can I do?
We’re all in this together
We’re getting there
Work with engaged people
People have the answers
People control their lives
Deficit Thinking:
Problem orientated
How to fix this problem?
Someone needs to sort this
Us versus them
Problems are embedded
Do things to people
People are a problem
People can’t be trusted to make decisions or be in control
Comfortable with complexity
• Leaders as “sense makers”• Allow solutions to emerge• Beware the “aye been”• Accept paradox and contradiction
Share power (or bring back Mutuality!)
• Embrace co-production• Cede power to get influence• Rights and responsibilities
Organizations Learning from Patients
The Old Way• Ryhov Hospital in Jönköping had traditional hemodialysis and peritoneal
dialysis center.• But in 2005, a patient, Christian, asked about doing it himself.
The New Way
Christian taught a 73-yr-old woman how to do it…
…and they started to teach others how to do it.
The New Way
• Now they aim to have 75% of patients to be on self-dialysis
• They currently have 60% of patients
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.”
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.”
And today?
• 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.”
To recap
Constancy of purpose
Compassionate governance
Stay true to your values (especially in the toughest times)
Change how you lead
Share your power
The heart, the soul and the act
• A nation’s culture resides in the hearts and in the soul of its people. • Mahatma Gandhi
• “It's the action, not the fruit of the action, that's important. You have to do the right thing. It may not be in your power, may not be in your time, that there'll be any fruit. But that doesn't mean you stop doing the right thing. You may never know what results come from your action. But if you do nothing, there will be no result.” • Mahatma Gandhi