change management in healthcare quality -...

Imagination at work.

17 August 2015

Change Management In Healthcare Quality

Privileged & Confidential

Oghogho Olakunri

GE Healthcare Partners - EAGM

2 GE Title or job number

8/17/2015

What contributes to poor quality in Healthcare?

“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”

Quality of care is…

— Institute of Medicine, 1990

Merely making health services accessible does not ensure they will be utilized Research in many settings has shown that demand for immunizations and other primary health care services rises with the quality of those services To attain and maintain healthy populations, countries must find ways to improve the quality of care on offer

Why emphasize quality of care?

Six Aims of IOM:

I. Safe II. Effective III. Patient Centered IV. Efficient V. Timely VI. Equitable

What is HIGH QUALITY care?

http://youtu.be/5vOxunpnIsQ 5

http://youtu.be/5vOxunpnIsQ

http://youtu.be/5vOxunpnIsQ

What is HIGH QUALITY care?

Safe • We are not harming people with our care

• We are not adding to the burden of illness

Effective • Matching science to care

• Avoiding overuse of interventions that don’t help, ensuring use of those that

help and avoiding underuse

Patient-centered

• People should be in control of their own care

• They should make decisions about what affects them

• Nothing about me without me

Timely • Avoiding delays

• Reduction of non-instrumental delay

Efficient • Avoiding waste including waste of equipment, supplies, ideas, and energy

Equitable • Justice in healthcare

• Care quality should not vary based on socioeconomic status, geographical

location, gender, religion etc

Healthcare needs to improve in these six areas

6

Donabedian Quality of Care Framework

The most common quality of care framework

• The context (structure) in which care is delivered affects processes and outcomes

• Outcomes indicate the combined effects of structure and process

7

Structures Processes Outcomes

the attributes of

settings where care is

delivered

whether or not good

medical practices

are followed

impact of the care on health status

9

The Nigerian Healthcare System

•Federal Ministry of Health

•National health policy

•Policy planning

•Policy guidance

•Tertiary care, Teaching hospitals

•State Ministries of Health

•Health management boards

•Secondary care, state hospitals

•Local Government Secretariat

•Basic health services

•Community health, hygiene and sanitation

• Responsibilities for healthcare split between three layers

of government (Federal, State & Local Govts)

• Healthcare system based on the principles of three tiers:

primary, secondary & tertiary healthcare

• Healthcare provided by government, social & private

sectors

• Poor quality services across spectrum in Diagnosis,

Experience & Outcomes

• Massive loss of confidence in healthcare system

• Household out-of-pocket expenditure constitutes

majority of healthcare expenditure

• Majority of the population look to private sector for

their healthcare needs

Tertiary 56 hospitals

Secondary 1200 hospitals

Primary 10,600 PHCs

Despite growth, health indices & outcomes remain poor

10

Maternal Mortality

• 560/100,000 live births • 40,000 women each year • 14% of the global total

Infant Mortality

• 78/1,000 live births

• >500,000 deaths per year

• 11% of the global total

• 70% are preventable

Under-five Mortality

• 124/1,000 live births

• >800,000 deaths per year

• 13% of global total

Supply Side

• Infrastructure/Utility deficit

• Commodity stock-outs

• Equipment inadequacy

Demand Side

• Low for critical services

• Loss of confidence in system

• 38% women deliver with skilled provider

Health Facilities

• 23,000 (est 14,000 PHCs)

• Variable functionality/poor

• Shortage of human resources

•

Source: WHO Global Health Observatory Data Repository; WHO Country Health Profile; United Nations Child Mortality Report, 2013

Disease burden drivers

11

107885

32997

15072

57486 19086 21624

2621 7099

3355 5353

972 2281 2546 2588

4500 3712

8673

2835 3564

Injuries

NCDs

CMPN*

2012 CMPN: Communicable, Maternal, Perinatal and Neonatal conditions

Infections/ Parasitic

Respiratory infections

Perinatal Maternal Nutrition

Other unintentional injuries

Intentional injuries RTAs

Neuro- Psychiatric

CVD Sense organ disorders

Resp Cong anomalies

Cancers Digestive Diabetes / Endo

Communicable, maternal, perinatal and neonatal conditions predominant

0

5000

10000

15000

20000

25000Communicable, Maternal, Perinatal & Nutritional Diseases (2012)

0

1000

2000

3000

4000

5000

6000Non Communicable Diseases (2012)

Prevalence of non-Communicable Diseases (NCDs) rising


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How do we improve Quality in Healthcare?

Clinical Governance

A framework through which organizations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish

Clinical Governance is intimately tied to Clinical Quality

13

Value proposition….simply put….better patient care

2003

“American Healthcare gets it right 54.9% of the time”

The Quality of Health Care Delivered

to Adults in the United States

McGlynn et al, New England Journal of

Medicine, 2003, 348 (26):2635-45 June 26

1912

“For the first time in human history, a random patient,

with a random disease, consulting a doctor, chosen at random, stands a better than

50/50 chance of benefiting from the encounter”

Lawrence J. Henderson MD Harvard Professor of Medicine, Biochemistry and Chemistry,

1912

15

Integrated Governance

Corporate Governance Clinical Governance

Financial Ownership/shareholders Board of directors Creditors Financial/Institutional regulators

Education and Training Clinical audit Clinical effectiveness R&D Openness Risk management Information Management

The elements of clinical governance

Elements of Clinical Governance


8/17/2015

ED Attendance

Triage

OPD Clinic

Pre-op Assessment

Surgery

Discharge

My Pain and Anxiety were Quickly Managed

My surgery started on-time

My Doctor explained my test results clearly

I knew what I had to bring and do on the

day Someone was always

with me

My doctor explained my progress day by day

I was discharged on-time

I understood the risks and felt like I will be in safe hands

I had an appointment within a week

Post-operative Recovery

In-patient Ward

Admission

I knew how long I had to wait

My privacy was always

maintained

I was welcomed warmly

The surgical team

introduced themselves

My Family was kept well-informed

My nurse regularly

checked on me

I was offered information about what to expect for my surgery

The clinic was very easy to find

I was provided clear information about my

medication, follow-up and side-effects

A Snapshot of a Patient’s Journey & Perspective

The Four Evils of human behavior

When there is general agreement that the individual should have done other than what they did, and in the course of that conduct inadvertently causes or could cause an undesirable outcome, the individual is labeled as having committed an error.

Or gross negligence, involves a higher degree of culpability than negligence.

Reckless conduct differs from negligent conduct in intent: recklessness is a conscious disregard of a visible, significant risk.

Failure to exercise the skill, care, and learning expected of a reasonably prudent health care provider

The intentional rule violation occurs when an individual chooses to knowingly violate a rule while he is performing a task.

Human Error Negligent Conduct

Reckless Conduct Intentional Rule Violation

The Swiss Cheese Model

Source: Ian D Coombes, Danielle A Stowasser, Judith A Coombes and Charles Mitchell. Why do interns make prescribing errors? A qualitative study MJA 2008; 188 (2): 89-94. Adapted from J. Reason’s model of accident causation

The Swiss cheese model for clinical errors

Reducing risks patients involves: • Identifying common errors in service delivery

• Understanding the factors that contribute to these errors

• Learning from errors and complaints

• Taking action to prevent a recurrence of harm

• Putting systems in place to reduce risks

Minimizing risks that health workers are exposed to involves: • Ensuring that healthcare workers are

immunized against vaccine-preventable

infectious diseases • Ensuring that the work the environment in

hospitals is safe

• Continuous sensitization of health workers on

the need to minimize exposure to risks as well

as monitoring for compliance

Reducing risks to hospitals involves: • Sticking to the best possible employment

practices

• Ensuring that the hospital environment is

safe

• Implementing policies on public involvement

in healthcare delivery processes

1. Elements: Education and Training

24

How does an institution ensure high quality

care through education and training?

Qxn:

Elements: Education and Training

25

• Establishing rigor around credentialing and privileging

• Minimum CME requirements

• BLS, ACLS, ATLS, PTLS

• Availability of decision support materials and software (eg Up to date)

• All staff involved - not just physicians

2. Elements: Openness

26

Blame No Blame

Open reporting in a culture of continuous improvement , not continuous blame

Example: Openness

27

A hospital is trying to tackle hand hygiene across its wards and has installed disinfectant gel dispensers in convenient locations all over the hospital. However, compliance is an issue. The charge nurse on the floor is responsible for compliance and has flagged many cases in which the doctor has not complied with protocol. She feels that the doctors are the least compliant and are to blame for the recent outbreaks on the floor. However she is reluctant to report them because the doctors will get reprimands from their chairman….and they will in turn give her a hard time on the floors.

How can we overcome the lack of openness in reporting?

Some key points

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• When reporting, ensure anonymity: eg through web portal, anonymous form, and more importantly, do not make only one person responsible for reporting, it is everybody’s job.

• Have clear reporting channels and processes in place to deal with non-compliance or medical errors.

• But before reporting, encourage all staff to be “each other’s keeper”. If they see somebody doing something wrong, they should tell them without fear of repercussions.

Remember, it is all in the patients’ best interests

3. Elements: Risk Management

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Risks to patients: ensuring there are mechanisms and systems in place that minimize risk or medical error to the patient. Learning from mistakes and root cause analysis is key. Example : TIME-OUT before surgical procedure in which entire staff methodically

take time to double check patient identification and surgical site.

Risk to Practitioners: Hospitals are dangerous places. Proper protection, facilities and procedures have to be in place to safeguard your most prescious asset, your staff. Example: nov-Coronavirus (MERS) claimed a disproportionate amount of healthcare workers, which prompted strict quarantine procedures for all suspected cases.

CaradigmTM Intelligence Platform-PROTECT

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4 Days

Dashboard visualization

2 weeks

iPad Capture Tool

1 week

CIP Analytics

Capture Triage in hospitals, clinics, hubs • Relevant Vital signs • Symptoms • Contact with animals • Recent Travel

• Demographics • Chronic disease history

Possible Case/ under

investigation

Symptoms suggestive

Visualize Connecting the dots and visual management

• Radiology • Lab tests PCR : CBC,

LDH, AST etc

Probable Case Positive radiology- Blood tests

Confirmed PCR positive

Analyze: • Pathway compliance • Radiology response time • Lab turn-around –time TAT

• Possible/Probable/ Confirmed rates

• False positive/negative test rates

• Demographic trends

Fast-track demonstration of tools tailored for MERS:

Fully operational system (contingent on data access, MoH resources committed, scale, cloud space, etc. )

• Real- time data and surveillance • Highly Flexible system that can

be used in the future for many disease scenarios whether infectious or other

4. Elements: Clinical Effectiveness

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What is it? Thoughts?

The measure of the extent to which a clinical intervention worked – in light of the clinical intervention and the extent to which it represents value for money, based on international guidelines and protocols for different diseases. It involves health service research and scientific reviews to improve health service delivery through periodic reviews to reflect insights from such analyses It is important for hospitals to pay attention to clinical effectiveness because hospitals and healthcare practitioners all over the world are increasingly being asked to justify their clinical practice or risk law suits with varying severity of consequences.

5. Elements: Clinical Audit

32

What is it? Thoughts?

A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change

• A way of improving care

• Use a multi-disciplinary approach,

• Logical and systematic

• Introspective

• Patient focused

Clinical Quality Improvement (CQI)

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Clinical Effectiveness

Clinical Audit + Evidence Based

Medicine Clinical Quality Improvement +

CQI has evolved to tackle the “evidence into practice gap”: EBM and CQI go hand–in-hand 1

Evidence Based Medicine (EBM) • Coined by Gordon Guyatt in 1992 for

JAMA • Described the bedside use of research

to improve patient care • Adopted in a variety of ways including

the development of clinical practice guidelines

Clinical Quality Improvement (CQI) • Emerged in the 1980’s; focus on

recurrent problems within systems • Adapted to healthcare from W. Edward

Deming’s work in industrial Japan • Led to the establishment of the

Institute of Healthcare Improvement (IHI) and the PDSA model

‘Doing the right thing’

EBM + CQI = ‘Doing the right things right’

‘Doing things right’

Source: 1 Glasziou, P; Ogrinc, G; Goodman, S. Can evidence-based medicine and clinical quality improvement learn from each other? BMJ Qual Saf 2011;20 (Suppl 1):i13-i17)

34

One of the main drivers for CQI is the problem of clinical variation

Clinical Variation describes differences in care that is delivered to

patients with the same condition

“If all variation were bad, it would be easy to stop it . What is difficult , is reducing the bad variation while keeping the good.”1

– Dr Al Mulley, Dartmouth Institute

Some clinical variation is appropriate…

“good” or “warranted”

Care is patient-centred

• Clinical differences • Personal differences

The majority of clinical variation is inappropriate…

“bad” or “unwarranted”

Care is not evidence-based • Omission • Commission

SOURCE: 1Mulley, AJ. Improving Productivity in the NHS. BMJ 2010. 341:c3965

35

Our understanding of clinical variation is growing

DARTMOUTH ATLAS1

First published 1999 Examples of variation in the US: • Diabetics in Chicago – 50% less

likely to receive lipid monitoring

• Medicare pays 2 x more per patient in Miami than in Albuquerque with no difference in life expectancy

NHS ATLAS OF VARIATION2

First published Nov 2010 Examples of variation in England: • 35 fold variation in diabetics

receiving established 9 key care processes

• 4 fold variation among stroke patients who spend <90% of stay on stroke unit

SOURCE: 1http://www.dartmouthatlas.org; 2http://www.rightcare.nhs.uk/index-php/nhs-atlas/

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The case for Clinical Quality Improvement

Source: 1McGlynn E. The Quality of Healthcare delivered to Adults in the US. NEJM. 2003: 348; 2635-2645; 2Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001; 3Crump H. ‘Variation shows NHS community services ripe for efficiencies’. Health Service Journal, 13 August 2009; 4Appleby J, Ham C, Imenson C, M Jennings. Improving NHS Productivity, more with the same, not more of the same. The Kings Fund. July 2010.

Evidence–based medicine is essential to high quality and cost effective care Inconsistent delivery of best practice, results in up to 45% of patients failing

to receive the recommended, evidence-based package of care1

Untended variation has a significant impact on quality and cost - $12 billion in avoidable medical expenses and deaths in the US2 and an estimated savings of £4.5 billion achievable among hospitals in England3

Lower cost base while improving quality … “Many of the most significant opportunities to improve productivity will come from clinical decision-making & reducing variations in

clinical practice.” ~ The Kings Fund4 ~

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Elements: Clinical Audit

Part of Clinical Quality Improvement

• Could include structure, processes and outcomes.

• Measures against standards and/or

explicit criteria

• Changes are implemented at an individual,

team or service level.

• A re-audit used to reconfirm

• Topics should reflect priorities or areas of

concern

• Is a multi-disciplinary activity

• Looks at the patient journey

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Select a topic for the audit

Define standards

Measure performance

against standards

Review standards in the light of

performance

Adapt the health service

delivery system

Start

The formal clinical audit process

While the audit looks like it is an inspection, the focus should be on improving the process

Identifying the process Who should say what the process should be ?

Lobby Time Time to Park Car

Registration

Walk to Procedure Area

Procedure Time Time to drive to facility

Hospital’s View of “Registration”

Patient’s View of “Registration”

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Define Measure Analyze Improve Control

Lean

Six Sigma

Plan Do Check Act

PDCA

Preparation

& Training

Assessment

& VSM Kaizen Sustainability

Post-Kaizen Assessment

Process Improvement

41

Continuous Quality Improvement

42 Time

Qu

alit

y

improvement security

CQI Cycle: PDCA

Do

Check Act

Plan

Measuring is key….but what is a Quality Indicator?

An Indicator is a Quantitative Measurement that is Rate Base (Numerator and Denominator) rated over time for comparison to standard

benchmarks and used for quality improvement projects

Face Validity

Precision

Minimum Bias

Application

Foster Quality

Improvement

Construct Validity

Indicators must be key to organizational success

5. Element: Research and development

44

R&D is not something to be done just at a personal level but at an institutional level… .this means it needs institutional governance

Two major governance structures are needed: Scientific committee which decides on whether a research proposal is aligned with the healthcare institution's research priorities. ( Funding priorities, availability of resources, and whether the proposal has sound scientific foundations) Internal Review Board (IRB) which approves whether the research

proposal/methodology conforms with the standard of ethics for medical research.

Facilitate Research Partnership / Monitoring and Evaluation

Establishing Research Liaison Office that will :

Saudi

Center for

Evidence

Based Health Care

Validate

EBHC

Directorate

for Research

and Studies

Department

of Statistics

Take into account Research Priorities in shortlisting CPGs adaptation

Take into account recommendations for increased research in areas of weak evidence in the CPG adaptation process

Use data to drive research around compliance and implementation correlating it to population health monitoring through tools such as Corvix

6. Element: Information Management

The Governance of collection, management and use of patient

records and information.

Examples of systems that fall within this jurisdiction are:

1- Paper or electronic health records

2- Radiology management systems

3- Lab management systems

4- Advanced Analytics

Safeguarding patient privacy and minimizing unnecessary access are key

What Excellence in Clinical Quality Improvement looks like….and how they did it

“being not bad does not mean you are good.”

~ Dr D Lappe,

Head of Cardiovascular Clinical Programme, Intermountain Healthcare

47

The Intermountain Healthcare Story

Intermountain Healthcare: A pioneer and global exemplar of Clinical Quality Improvement

Facilities 23 hospitals 185 outpatient

clinics US (Idaho and Utah)

Employees 4,500 total

physicians 33,000 total

employees Information Systems

1,025 FTEs Approximately $200

million budget pa

US Integrated Delivery System

Intermountain is the only organisation in the US to have been ranked as the No. 1 Integrated

Delivery System 5 times - based on efficiency, communication, cost and quality of care

Source: 1James, B, Savitz L. How Intermountain trimmed healthcare costs through robust quality improvement efforts. 2011: no 6; 1185-1191

http://www.youtube.com/watch?v=mPIUE

Y2GD5U 48

http://www.youtube.com/watch?v=mPIUEY2GD5U

http://www.youtube.com/watch?v=mPIUEY2GD5U

Sustaining the delivery of clinical quality across a large system

Clinical Programs

• Focus on what’s important – variation, activity, cost

• Agree standardized ‘best practice’ pathways – “Shared baselines”

• Implement evidence-based practice standards and monitor clinical

performance against these standards

• Establish a common model for change

• Build a quality improvement culture around data-driven decision

making and teamwork

• Focus on agreed clinical programs…early adopter successes

• Capture, retrieve, analyze, report high quality pathway data

• Ensure data is trustworthy & timely…value add to clinicians

• Invest in electronic patient records and tools to pull near real time

data into clinical workflows

Organisation & Culture

Data & Technology

The three core elements of Intermountain’s CQI model

Intermountain’s journey began with rigorous analysis to prioritise improvement opportunities

50

Of the 1,400 clinical conditions managed at Intermountain, 104 of these account for

93% of the care it delivers

1,260 104

Co

mm

on

clin

ica

l co

nd

itio

ns

rep

rese

nt 8

% o

f

the

to

tal

Most frequent clinical conditions

Less frequent clinical conditions

11% attributed to Labour & Delivery

10% attributed to IHD*

Profile of Intermountain’s patient population (no. of different clinical conditions presenting to Intermountain hospitals; n=1,400)

*IHD-Ischaemic Heart Disease

Total number of clinical conditions presenting to Intermountain hospitals

Clinical & Operational Staff Clinical Expert Group

Focused analysis led to the development of over 70 ‘best practice’ clinical protocols (comprising 90% of Intermountain’s casemix)

Clinical Protocol Development Model1

• Review scientific literature

• Review Intermountain’s clinical

data repository Re

vie

w

• Ensure protocol is workable

through rigorous testing and

clinical engagement

• Agree with clinical staff, ‘shared

baselines‘ around best practice

• Define each data element (e.g.

symptom, physical obs, labs etc.) • Define expected timing for patient

Dx, Rx, recovery/follow-up

• Design clinical protocols and

embed into IT system according to

clinical workflow

De

fin

e &

De

sig

n

With collectively agreed, best practice ‘shared baselines’, about 80% of all care delivered

is evidence-based, compared with a US industry average of 55% 2

Test

M

on

ito

r &

Su

sta

in Both teams are permanent & jointly:

• Track scientific literature and

Intermountain’s own data

• Monitor compliance to agreed protocols, with near real time

documentation of variance

• Make minor adjustments to

protocols on a monthly basis

• Make major revisions every 2 yrs

1

2

3

4

Source: 1 Bohmer, R. Fixing Healthcare on the frontline. Fixing healthcare from the inside & out. 2011. Harvard Business School Publishing Corp. 2McGlynn E. The Quality of Healthcare delivered to Adults in the US. NEJM. 2003;: 348; 2635-2645. http://www.nejm.org/doi/pdf/10.1056/NEJMsa022615

51

Disrupting ‘traditional’ care delivery structures in favour of ‘clinical programmes’ was essential for success

Clinical Integration Matrix Intermountain’s clinical integration model includes 9 clinical programmes (the ‘verticals’)

centred around its 70+ agreed, localised, evidence based clinical protocols. Each programme is physician led and is accountable for ensuring successful delivery of the specific clinical protocols

across the continuum of care (hospital to community). Various supporting ‘horizontal’ functions, work intimately with

each programme to assist teams in providing consistent delivery of care.

Examples of

‘horizontal’ supporting functions

Intermountain’s existing clinical programmes: the ‘verticals’

Although the model is flexible, Intermountain data shows that clinical protocols, based on ‘shared baselines’ and supported by the clinical programmes, leads to minimal

variation, with only 5 to 15% warranted variance occurring across its system.

Source: James, B ; Lazar, J. Sustaining and extending clinical improvements. (Chapter 7) A framework for the continual improvement of healthcare: building and applying professional and improvement knowledge to test changes in daily work. Joint Commission Journal of Quality Improvement 1993; 19(10) 424:424-52 )

52

Embedding a culture of CQI, with core knowledge and skills among clinical staff is key to sustainability

Continual Improvement

• Change the clinical and

administrative culture - impacting a

sufficient number of staff to embed

the change system wide ( “square

root of n”)

• Build on the foundation of the

‘healing professions’ and take clinical

staff on the improvement journey

• Demonstrate benefits to the

organisation of releasing clinical staff

to attend training

3 key aims for CQI training

Professional

knowledge Subject matter

expertise Discipline Values

Improvement

knowledge • Processes /

systems • Variation Mgmt • Change Mgmt

CQI training for Clinical Staff

Source: A framework for the continual improvement of healthcare: building and applying professional and improvement knowledge to test changes in daily work. Joint Commission Journal of Quality Improvement 1993; 19(10) 424:424-52 (Ocr)

Intermountain has trained over 3000 of its clinical staff in clinical quality improvement methods to successfully support change

53

Intermountain is regarded as one of the most advanced users of IT and data to drive sustainable continuous quality improvement while lowering cost

Results… Elective induction <39 wks was reduced from

30% to less than 3%

What the guidelines state… Elective induction should not be preformed <39 wks

1.12%

0.45%0.21%

37th Week 38th Week 39th Week

Sustained

Percentage on Ventilator

Leveraging data and technology to transform patient care and reduce variation: A case study

What the data showed… . Increased risk of ventilation-associated

complication with elective induction <39 wks

$1.5M recurring savings + quality improvements

54

CQI success highlighted by measuring performance against ‘best practice’

Core Measures • US clinical quality performance

measures • Initially part of Joint

Commission accreditation; adopted by Medicare/Medicaid

• Used to benchmark hospital

clinical performance and spur improvement

• Focused on high volume, high variation areas: MI, CHF, Pneumonia, Surgical care

SOURCE: 1 Kfoury A, Incremental survival benefit with adherence to standardized heart failure core measures: A performance evaluation study of 2958 patients. Journal of Cardiac Failure 2008. Vol 14 (7); 95-102.

Intermountain’s 12 month mortality results shows improved outcomes when heart failure patients get all four recommended interventions or the “full package of evidence-based care”. This includes: 1) Discharge instructions; 2) Evaluation of LV function; 3) ACE or ARB for LVSD; 4) Smoking cessation advice.1

55

Further examples of Intermountain’s system wide clinical quality improvement successes

• Perioperative cardiovascular surgery glucose control led to significantly reduced morbidity, mortality and costs

• Discharge med program for coronary heart disease and heart failure patients significantly reduced readmissions, mortality, and costs

• Reduced blood transfusions by 50% in open heart surgery patients, making considerable savings and improving predicted outcomes

• Comprehensive patient education combined with “Partners in Healing” programme (involving family in the care and discharge process of cardiovascular patients) has reduced readmissions and complications

• Integrated imaging network allows rapid reading of imaging studies and access throughout their system to reduce repetition of tests and reducing time to diagnosis and treatment

Intermountain can point to more than 100 successful clinical improvement initiatives introduced since 1995

56

Summary of key CQI lessons learned

1) Most variation is due to process failure, not individual failure – improve the processes

so that they support staff to “do the right thing

2) Focus improvement efforts on high-volume, high cost, high variance clinical areas

3) Understand the evidence base and analyse the data against this

4) Agree ‘shared baselines’ and ‘localise’ best practice

5) Identify and target barriers to optimal care

6) Integrate clinical and operational staff to support quality care

7) Leverage IT to capture, analyse, share and report essential data to frontline clinicians

in near real time….not 6 months later when clinical decisions have already been made.

8) Apply knowledge generated by day-to-day care to build ongoing, continuous learning

Fundamental CQI Lessons

57

Why does Change Matter?


8/17/2015

Managing Change in Healthcare

GE’s Change Research

100% of all changes evaluated as “Successful” had a good technical solution or approach

Over 98% of all changes evaluated as “Unsuccessful”

also had a good technical solution or approach

____________________________________________

What is the differentiating factor between success and failure?

8/17/2015 Privileged and Confidential 61

The Change Equation

Quality

Q x A = E 3

Acceptance Accountability

Alignment

Effective Results


Effective Leadership Practices

Change initiative focused on

customer needs (target)

Speed = Integrating Problem Solving with Engagement

Implementing change Q x A3 = E

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“We cannot solve problems with the same thinking we used

when we created them."

Albert Einstein

GE Internal - For internal distribution only.

Root Cause Analysis

Symptoms

Root Causes

ROPE OF SCOPE

FUNNEL OF FOCUS

Change Paradigm

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Creating a Shared Need

… Burning platform

… Sense of Urgency

… Challenge the status quo

Threat vs. Opportunity Matrix

Three “D’s” Matrix

– Data

– Demonstration

– Demand

Tools:

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Uses: Building the case for change is one of the first and most important tasks of the team. This simple tool helps the team discover how to frame the need for change more broadly and perhaps break some old habits about change only as it applies to a short-term threat.

Threat vs. Opportunity Matrix

Tool: Threat vs. Opportunity Matrix – Best Practice organizations know how to frame the need for change as more than a short-term threat. They work to find ways to frame the need as a threat and opportunity over both the short and long-term. By doing so, they begin to get the attention of key stakeholders in a fashion that ensures their involvement beyond what can be gained from a short-term sense of urgency.

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Three D's matrix


Data/Diagnosis

-Internal sources

-External sources

What data do we have or need?

Demonstrate

-Leading by example

-Best Practices

-Visiting other organizations

Show Me! Where is it working/not working?

Demand

-Dynamic Leadership

-High standards

-Regulatory

Who or what is driving it?

Approaches Ideas Actions

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99.99966% Good (6 Sigma)

Unsafe drinking water for almost 15 minutes each day

52 incorrect site surgeries every 5000 surgeries

Two short or long landings at a

major airport each day

10,000 wrong drug prescriptions per 1 million filled each year

Unsafe drinking water for one

minute every seven months

1.7 incorrect site surgeries every 500,000 surgeries

One short or long landing every five years at a major airport

3.4 wrong prescriptions per 1 million filled each year

99% Good (3.8 Sigma)

Using Six Sigma performance


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Mobilizing Commitment

Why bother?

Need sufficient support and involvement from key stakeholders

Critical mass must be won over

Key difference between success and failure

What are we after?

Coalition of committed supporters

Identification of potential resistance

Conversion of key influencers

Mobilizing Commitment positions the team for downstream interventions.

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Two Sides of the Coin

Intentional (those who make the decisions)

THEM

• envisioned by leaders

• is a conscious decision

• is anticipated

• is gradual

• is incremental

• is paced

• solves problems

• provides new opportunities

Imposed (those required to implement the decisions)

US

• is a decision without choice

• is unexpected

• is dramatic (lightening bolt)

• is rapid (out of control)

• creates problems

• disrupts routines

Adapted From: Managing at the Speed of Change by Daryl R. Conner

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…so quality improvement in Healthcare is about CHANGE

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Thank you!

Oghogho Olakunri

[email protected]

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change management in healthcare quality -...

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