IOM's Quality Through Collaboration:
Ya Sure, Minnesota Can Do That!
Clint MacKinney, MD, MS
clintmack@cloudnet.com
Duluth, Minnesota
July 18, 2005
2005 Minnesota Rural Health Conference
Topics for Today
1. A brief introduction to the Institute of Medicine’s
Quality Through Collaboration: The Future of
Rural Health
2. The healthcare landscape; why change is coming
(whether we like it or not!)
3. The elusive (but oh-so-important) topic of
organizational culture
4. The requisite of leadership
5. Patient safety is job one
6. Quality improvement follows on safety’s heels
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2005 Minnesota Rural Health Conference
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Committee on the Future of Rural Health Care
• Quality Through Collaboration:
The Future of Rural Health
– Institute of Medicine’s Quality
Chasm Series
– Available at www.nap.edu
– Executive Summary (.pdf) is free
• Five-pronged strategy to
address rural healthcare quality
challenges
• Key findings and
recommendations
2005 Minnesota Rural Health Conference
Five-Pronged Strategy
1. Addressing personal and
population health needs
2. Establishing a quality
improvement support structure
3. Strengthening human
resources
4. Providing adequate and
targeted financial resources
5. Utilizing information and
communications technology
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2005 Minnesota Rural Health Conference
IOM’s 30,000-Foot View
• Written from a national
perspective.
• Recommendations for
federal policy.
• Challenge is to “bring it
down” to local levels.
• Emphasis today – How we
can improve:
– Culture
– Leadership
– Safety and Quality
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2005 Minnesota Rural Health Conference
The Healthcare Landscape
–We do whacky things
–Questionable healthcare value
–Pay for performance
–Provider accountability
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Glitches Happen
Oops.
Uh, sorry
about
scratching
your truck.
2005 Minnesota Rural Health Conference
Every system is perfectly designed…
Look! It only takes
one guy and one
ladder to change a
light bulb!
(Timber!)
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…to achieve the results that it yields.
Ouch!
(or maybe)
D’ Oh!!
2005 Minnesota Rural Health Conference
Healthcare Safety Strategy?
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2005 Minnesota Rural Health Conference
The Healthcare Landscape
–We do whacky things
–Questionable healthcare value
–Pay for performance
–Provider accountability
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2005 Minnesota Rural Health Conference
Healthcare Value
Value = Quality + Service
Cost
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2005 Minnesota Rural Health Conference
Healthcare Value (Quality)
The Quality of Health Care Delivered to Adults
in the United States – McGlynn et al
Results
• Participants received 54.9% of recommended care.
• 45% defect rate!
Conclusions
• The deficits we have identified in adherence to
recommended processes for basic care pose serious
threats to the health of the American public.
NEJM. Volume 348:2635-2645. June 26, 2003. Number 26
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2005 Minnesota Rural Health Conference
Healthcare Value (Service)
Overall Mean Score Inpatient Satisfaction
87
86
85
84
83
82
81
All Other
Hospitals
Rural
Hospitals
Critical
Access Hosp
Press Ganey National Database. Presented at HealthLeaders Forums. 2005.
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2005 Minnesota Rural Health Conference
Healthcare Value (Cost)
30%
70%
Costs of Poor
Care
Appropriate
Health Care
Costs
Causes of poor care: Misuse, underuse, overuse, waste – Juran Institute and Midwest
Business Group on Health. 2003
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Healthcare Value (Cost)
% Who Think Prices are Unreasonable High
70%
60%
50%
40%
30%
20%
10%
0%
Clothes
Food
Cars
Doctors
Harris Interactive Poll (quoted by Steve Wetzell, 2005)
Drugs
Hospitals
2005 Minnesota Rural Health Conference
The Healthcare Landscape
–We do whacky things
–Questionable healthcare value
–Pay for performance
–Provider accountability
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2005 Minnesota Rural Health Conference
Pay for Performance
• Developing force for change
– Approximately 100 programs
– 1/3 commercial plans
– Impacting both hospitals and
physicians
• Does it work?
– Improved quality
– Decreased utilization
– Success seems to depend on size
and type of incentive
Int J Qual Health Care. 2000:12:133-42
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P4P - The Social Democrats
• A rising tide lifts all boats
• Broad participation is
important
• Set achievable goals to start
• Reward improvement as well
as performance
• Technical assistance to help
all groups succeed
Steve Wetzell. The Movement Towards Transparency
and Pay for Performance. 2005.
Healthcare providers “need
payment not for performance,
but to support performance.”
– Don Berwick, 2005
2005 Minnesota Rural Health Conference
P4P - The Darwinians
• “If you build it, they will
come”
• Set the bar high
• No breakthrough without
pushing
• Make threshold more
difficult over time
• Poor performers will
(should) get consolidated
Steve Wetzell. The Movement Towards Transparency
and Pay for Performance. 2005.
Accelerating
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The Healthcare Landscape
–We do whacky things
–Questionable healthcare value
–Pay for performance
–Provider accountability
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Accountability Agents
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New Paradigm
“No margin – no mission”
to
“No outcome – no income”
– Charles Denham
National Patient Safety Foundation
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Questions About the Future
• Should rural healthcare providers feel complacent
with cost-based reimbursement, grant funding,
and minimal quality reporting mandates?
• Are we in rural insulated and immune from the
forces of healthcare change?
• Should our patients continue to tolerate
healthcare overuse, underuse, and misuse?
• Should our patients continue to tolerate
suboptimal safety, quality, and service?
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Cornerstones of Success
Safety and
Quality
Patient
Experience
Community Health
Financial
Stability
Employee
Growth
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2005 Minnesota Rural Health Conference
Culture
What does “culture” mean to you?
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Culture
• Culture is the invisible force
behind the intangibles and
observables in any organization, a
social energy that moves people
to act. Culture is to an
organization what personality is to
the individual – a hidden yet
unifying theme that provides
meaning, direction, and
mobilization.*
• What we believe; what we do
* Kilman,
Sexton, Serpa, 1985
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Cultural Barriers to Safety
We have not seen substantial progress in one critical
area – culture – that has the greatest potential to
produce sustainable improvements in safety.
– Daniel Stryer and Carolyn Clancy
BMJ. March 12, 2005
Why isn’t health care demonstrably safer? … The
answer is to be found in the culture of medicine –
complexity, autonomy, fear, and lack of leadership.
– Lucian Leape and Donald Berwick
JAMA. May 18, 2005
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The “Worstest” Cultural Barrier
Because
we’ve
ALWAYS
done
that way!
it
Thanks to Sharon Vitousek, MD
North Hawaii Outcomes Project
and IHI
2005 Minnesota Rural Health Conference
Defining Mission
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Cultural Determinants
• Walking the Mission talk?
• The congruence of:
Mission – Operations – Budget – 3 Rs
• Questions for home:
– How do day-to-day operations support the Mission?
– How does the budget prioritize the Mission?
– How many staff and Board meetings are devoted to
the Mission?
– How are employees reinforced, recognized, and
rewarded for living the Mission?
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Performance Improvement
• Performance improvement is key
to an improvement culture
• The Zen of performance
improvement
– “In God we trust… All else show
data” (Michael Pugh)
– “You can’t manage what you can’t
measure” (unknown)
– “Not all that counts can be counted
and not all that is counted counts”
(Albert Einstein)
– “The world is not black and white; its
grayness makes life interesting and
often challenging” (me)
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Mission/Reality Conundrum
RWHC Eye On Health
Provided by Tim Size
"The math is simple, if we ignore our finances, we risk the
hospital; if we ignore our quality, we risk family and friends."
Rural Wisconsin Health Cooperative
2005 Minnesota Rural Health Conference
Leadership
What does “leadership” mean to you?
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IOM’s Comments on Leadership
• Finding
– Rural communities engaged in
health system redesign would likely
benefit from leadership training
programs.
• Recommendation
– Skills sets such as coalition building,
community engagement, health
status measurement, change agency
are necessary for transformational
change.
IOM. 2004. Quality Through Collaboration: The Future of
Rural Health. Washington, D.C. National Academies Press.
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Leaders’ Roles
• Establish direction
• Align people
• Motivate and inspire
• Plan and budget
• Organize and staff
• Control and problem-solve*
• Measure, reflect, improve,
and communicate
*Kotter, 1990
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Seeking “Balance”
• Seek balance among equally
important (and often
competing) priorities
–Mission, Operations,
Budget, and the 3Rs
–Quality, Patients,
Employees, and Finance
• With balance, “no margin; no
mission” becomes circular
and meaningless
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Leadership Action List
 Scan the external environment
and select cultural priorities
 Align strategy, operations, and
measures
 Encourage behaviors that support
a safety and quality culture
 Mandate a non-punitive work
environment
 Build improvement capability
 Remember: Attention is the
currency of leadership
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CEO Action List
 Implement patient safety survey
 Select a PI champion, but never
abdicate responsibility
 Communicate new cultural
emphases – again and again
 Oversee improvement aims at
highest leadership levels
 Manage with data
 Reorganize meeting structure
 Drive down decision-making
 Engage physicians
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QI Director Action List
 Make Quality more than a
department
 Categorize quality work for
optimal efficiency
 Develop a performance
tracking system
 Choose pertinent quality
measurements
 P–D–S–A
 Seek opportunities (glitches!)
for improvement
 Communicate and celebrate
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How Not to Start Meetings and Memos
“We need to improve morale
around here – any of you
boneheads have a good idea?”
“The beatings shall continue until
attitudes improve.”
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Safety and Quality
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Safety and Quality
• Safety and Quality?
• Organizational Culture?
• Both!
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Culture for Quality to Flourish
• Active leadership and personal
involvement
• Explicit quality mission and
quality targets
• Regular performance reporting
and accountability
• Safe environment for reporting
errors
Meyers, JA et al. Hospital Quality: Ingredients for Success – Overview and Lessons Learned. The
Economic and Social Research Institute. The Commonwealth Fund. #761. July 2004
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Attracting/Retaining the Right People
• Selective hiring and
credentialing
• Respect and empowerment of
nurses
• “Hire for attitude, train for
aptitude”
• Getting the “right” people on
the bus (Jim Collins)
Meyers, JA et al. Hospital Quality: Ingredients for Success – Overview and Lessons Learned. The
Economic and Social Research Institute. The Commonwealth Fund. #761. July 2004
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2005 Minnesota Rural Health Conference
In-House Quality Improvement Processes
• Identify where suboptimal care
is delivered
• Adequately staffed QI – lead by
physicians
• Deficiencies inspire discovery
and correction
• Evidence-based protocols
• Team-based care management
Meyers, JA et al. Hospital Quality: Ingredients for Success – Overview and Lessons Learned. The
Economic and Social Research Institute. The Commonwealth Fund. #761. July 2004
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Right Tools
• Information technology and QI
staff to abstract
• Investing and developing
culturally sensitive information
technology
• Physicians supported to develop
guideline consensus
• External training, peer
networking, conferences
Meyers, JA et al. Hospital Quality: Ingredients for Success – Overview and Lessons Learned. The
Economic and Social Research Institute. The Commonwealth Fund. #761. July 2004
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Communication
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Communication – The First and Last Defense
GLITCH
INJURY
2005 Minnesota Rural Health Conference
New Communication Strategies
• Handoff / handover
– “Never leave your wingman”
• SBAR briefing strategy
– Situation
– Background
– Assessment
– Recommendation
• Appropriate Assertion
• Critical language
• Huddle and Debriefing
Leonard, M., et al. Achieving Safe and Reliable Healthcare: Strategies and Solutions. Health
Administration Press. Ann Arbor, Michigan. 2004.
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Quality Improvement Strategies
• Assess variation
• Care protocols
• Care maps
• 100k Lives Campaign
– Rapid Response Team
– AMI care
– Surgical site infection
– Adverse drug events
– Central line infection
– Ventilator pneumonia
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In Support of the Cornerstones
• Define and engender
improvement
• Lead and facilitate
change
• Support and nurture the
organization
The cornerstones
become your vision
•
•
•
•
•
Safety and Quality
Patient Experience
Financial Stability
Employee Growth
Community Health
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Changes
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Goal: Healthy Communities
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