Strategy, Curriculum, and Structure for Continuous Improvement

Steven J. Choi, MD, FAAP Assistant Vice President

Director, Montefiore Network Performance Improvement Executive Director, Montefiore Institute for Performance Improvement Associate Professor of Pediatrics, Albert Einstein College of Medicine

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Agenda 1. Brief Overview of Montefiore Health System 2. Evolving Healthcare Quality Landscape 3. Role for Improvement Capacity in Healthcare 4. Creating a Sustainable Structure for a CQI Culture 5. Sample of PI Results 6. Questions/Discussion

Montefiore Medical Center • Beds: 1,491 (4 Hospitals) • Medical School: Albert Einstein College of Medicine • Faculty: 1,600 • Academic Departments: 21 • Resident and Fellowship Programs: 94 (ACGME) • Residents and Fellows: 1412 (7th largest teaching

hospital in the US) • Annual hospital admissions: 93,000 • Annual ER visits: 300,000 • Annual Ambulatory visits: More than 2.6 million

Montefiore Health System • Affiliated Hospitals (9):

– Burke Rehabilitation Hospital – Montefiore Mount Vernon Hospital – Montefiore New Rochelle Hospital – Nyack Hospital – St. Luke’s Cornwall Hospital – White Plains Hospital – St. John’s Hospital – St. Joseph’s Hospital – Westchester Square Hospital

• Focus: primarily on retrospective (often random) review of voluntarily reported cases/events

• Majority of resources allocated to regulatory mandates, surveys, and peer review

• Notion that there was always a single cause and effect relationship for every major event (culture of blame)

• Lack of focus on systems and processes • Lots of measurement but not much, if any,

improvement

Traditional Healthcare Quality Systems

(Most US Hospitals and Medical Centers, Pre-2000)

Plague of 3 Classic Healthcare Improvement Myths:

1. Meetings = Improvement 2. Spreadsheets = Solutions 3. Emails = Execution

So what happened in 2000 (around 2000)?

What changed in healthcare?

How do (did) we try to improve healthcare???

• Assign and Task • Increase Awareness • Provide Performance Feedback • Develop New Policies and Procedures • Create Incentives • Resort to Punishment and Penalties • Promote Good Will • Work Harder, Try Harder, Do Gooder

4 Common Themes for Poor Performance (The IHI experience with 40 organizations working to achieve higher levels of reliability for CMS Core Measures)

1. Current improvement methods in health care are excessively dependent on vigilance and hard work.

2. The current practice of benchmarking to mediocre outcomes in health care gives clinicians and leaders a false sense of process reliability.

3. A permissive attitude toward clinical autonomy creates and allows for wide, and unjustifiable, performance variation.

4. Processes are rarely designed to meet specific, articulated reliability goals.

Health Serv Res. 2006 Aug; 41(4 Pt 2): 1677–1689.

VIGILANCE and HARD WORK FALSE SENSE of PROCESS RELIABILITY CLINICAL AUTONOMY and VARIATION PROCESSES not designed to meet OUTCOMES

Re-Engineer our Delivery System

Application for Performance Improvement

Clinical Quality

Patient Safety

Operational Efficiency

Performance Improvement

Tribute to 2 Great Pioneers and Pioneer Organizations in

Healthcare Re-Design

Intermountain Healthcare

• In 1991, through the Institute for Health Care Delivery Research developed the Advanced Training Program (ATP).

• Led by Dr. Brent James, developed the 1st training programs for healthcare leaders, executives, and front-line providers in quality improvement.

• Partnered with IHI for rapid scaling throughout the world. • Over 3,500 graduates.

Institute for Healthcare Improvement (IHI) • Founded in 1991, led by Dr. Don Berwick • Redesigning health care • 100K/5 Million Lives Campaign. • Created the Triple Aim • Developed the Model for Improvement with

API (Associates in Process Improvement), led by Lloyd Provost

Peer Review Quality

Assurance

Performance Improvement

Regulatory and Endorsed

Metrics

How important is CHANGE?

“All improvement requires change,

but not all change

results in improvement”

Don Berwick, MD Past President and CEO, IHI

Former Director, CMS

Why change our system? “Every system is perfectly designed

to get the results it gets.” Don Berwick, MD Paul Batalden, MD

Joseph Juran

Improvement Science • Getting people to do what they are supposed to

do is a science as much as it is an art. • Implementation of best practices is really,

really, really hard. • Innovation is critical to change and successful execution • NOT by the following:

1. Try harder……….. 2. Be better……….. 3. Do gooder…………

• WORKING SMARTER

Montefiore Institute for Performance Improvement: Faculty and Staff

• Executive Director • Instructors • Facilitators • Coaches • Program Coordinator • Background: MD’s, Administrators (MPH, MHA,

MBA), and Engineers (HSE) • PI Training: IHI, Intermountain, Lean, Six Sigma,

Simpler

Montefiore Institute for Performance Improvement Key Programs

1. PI Fellowship-Intensive training program for improvement leaders

2. CQI Events (Kaizen)-Large transformation collaboratives

3. Improvement Advisor-Consultation and Coaching services for individual projects, ad hoc

PI Fellowship

1. 12 month improvement science curriculum which includes: 2. Completion of IHI (Institute for Healthcare Improvement)

– Training certificate in Quality and Safety 3. Design, implement, and complete QI Project (Institutional

Goals) 4. Meet with assigned PI Coach (minimum-monthly) 5. Standing meetings with improvement team (minimum-monthly) 6. Disseminate PI education with local service area 7. Function as a QI mentor (advisor) for next year’s class

Transformation Model Process(es)

Frontline Workers

Project Team Members

Multidisciplinary Team

Guidance Team

Project Leader PI Coach

PI Fellows

PI Course Instructors/Facilitators

Assigned PI Coaches

(Monthly/Bi-monthly check-ins)

Outcome(s)

(Monthly team meetings)

(PI Course Training)

Process Owners

(Disseminate PI knowledge)

Adapted from: https://intermountainhealthcare.org/about/transforming-healthcare/institute-for-healthcare-delivery-research/courses/advanced-training-program

Who Do We Train? • Front-line (Process Owners) • Administrative Leadership (CEO, VP’s) • Physician Leaders (Chair, Vice-Chair, Chiefs) • Nursing Leaders • Quality and Safety Leaders • Pharmacy • Respiratory Therapy • Operations Managers • Class Size: 15-20

4 Major Components of Fellowship

Self-Learning

Group Workshops Coaching

Improvement Project

(2-4 hrs/month)

(2-4 hrs/month)

(8-10 hrs/month)

(1-2 hrs/month)

Self-Learning IHI Modules Assigned IHI Modules

• QI 101: Introduction to Health Care Improvement

• QI 102: How to Improve with the Model for Improvement

• QI 105: Leading Quality Improvement

• PS 101: Introduction to Patient Safety

• QI 103: Testing and Measuring Changes with PDSA Cycles

• QI 104: Interpreting Data: Run Charts, Control Charts, and Other Measurement Tools

• PS 102: From Error to Harm

• PS 103: Human Factors and Safety • PS 104: Teamwork and Communication in a Culture of Safety

• PS 105: Responding to Adverse • L 101: Introduction to Healthcare Leadership

• TA 101: Introduction to the Triple Aim Populations

• PFC 101: Introduction to Patient-Centered Care http://www.ihi.org/education/IHIOpenSchool/Pages/default.aspx

Key Skills for Health Care Delivery Improvement

PI Methods and Tools

Leadership

Change Management

PI DIDACTICS PI LAB EXERCISES

• Overview of Course Goals/Expectations • History and Evolution of Healthcare Quality

Improvement

• Introductions/Ice Breaker • Designing a PI Project (Creating Donabedian Model) • Marshmallow Tower #1

• IHI Model for Improvement • Key Drivers/ Metrics/ Change Concepts/Affinity Diagram

• Smart Aim • Brainstorming/Affinity Diagrams • Designing a PI Project #2

• 5 Why's/RCA/GEMBA • Process Maps • Stages of Team Development

• Process Mapping • 5 Why’s

• Pareto Principle • Pareto Principle Case Studies

• Mastering PDSA Cycles • Modified Red Bead Game

• Run Charts/Control Charts • Leading Change in Change Management

• Change Management Exercise • (More of/Less of, PICK Chart, Threats/Opportunities)

• Introduction to Lean Healthcare (7 Wastes) • Lego Factory

• Human Factors in Healthcare • Team STEPPS

• Human Factors Exercise • Team STEPPS (Paper Chain)

• Leadership • Marshmallow Tower #2

• 5S In Healthcare • 5S Picasso Game

• 6 Sigma in Healthcare (reducing variation) • Statapult

• Being a QI Coach/Facilitator • Coaching Kata • Jigsaw Puzzle Kata

• Sustainability of Success • Marshmallow Tower #3

• High Reliability • Scavenger Hunt

LEARNING BY DOING: DEVELOPING A PI LAB

Sequence for Learning PI Skills

Self-Learning

Formal Didactic

PI Lab Exercise

Application in PI Project

Stop Chasing the Outcomes

Outcome Measures • Key Performance Indicators (KPI’s) • Lagging Indicators (Takes time to see real change) • “The Scoreboard” • Don’t just stare at the scoreboard

Process Measures • Key Drivers (lead to the outcome you desire) • Leading Indicators (Can change very quickly) • Process is what we can control (directly) • Measuring processes (key drivers) is the ONLY way to understand

why you are succeeding (winning) or failing (losing)

Critical Role of Change Concepts • This is at the heart of performance improvement • Innovation leads to transformation • Without innovative changes, you will fail

– “Don’t forget to take your asthma meds……..” – “Make sure to avoid sugary foods……….” – “We need to control your blood pressure because

hypertension is bad for you……..”

Why Invest in a Local PI Training Program ? 1. Sending employees to 3rd party: $$$ 2. Bringing in 3rd party: $$$ 3. Most external programs offer consolidated 1-2

week programs (vs. long-term, longitudinal) – Difficult to really learn PI in 1-2 weeks – Can’t learn without application (project)

4. Providers and administrators are busy (travel) 5. Need for on-site coaching 6. Train the masses (critical mass)

Return on Investment (ROI) For the Individual Trainees:

1. Unique skillset for professional and personal improvement

2. IHI-Certificate of Training 3. CME/CEU credits-over 60 hours 4. MOC (Maintenance of Board Certification) for medical

boards 5. Career Development and Leadership Portfolio 6. Publishable Manuscript

Return on Investment (ROI) For the Organization:

1. Develop project champions and structured improvement teams for key strategic quality initiatives

2. PI Champions embedded throughout medical center, eventually: – Across ALL medical disciplines – Across ALL service/operational departments – Across ALL campuses

3. Organizational transformation/Culture Change

Performance Improvement 1. Measurement is the ONLY valid method to provide

OBJECTIVE AND QUANTITATIVE VALUE to a subjective perception of what is (or isn’t) improving.

2. Measure the process NOT just the outcome (otherwise you cannot conclude that your changes resulted in the improvement)

3. Without changing the process there is NO real improvement. (You’re just lucky, a.k.a. random variation)

3 Commandments of Performance Improvement

Thank you!