Leading Together UT System Clinical Safety and Effectiveness Conference October 27, 2011 Maureen Bisognano President and CEO IHI Aims for Today • Look out at the challenges we share in the coming year • Look around for ideas and models • Look in and celebrate the amazing work you are doing Our Challenges • Structural challenges in this time of reform • Health needs and challenges in the populations we serve • Managing the complexity in caring for patients Making Sense of It All Scores: Dimensions of a High Performance Health System 75 73 70 Healthy Lives 70 71 Quality 2006 revised 2008 revised 2011 75 * 67 Access 57 55 52 53 53 * Efficiency 69 71 69 Equity 67 65 64 OVERALL SCORE 0 100 * Note: Includes indicator(s) not available in earlier years. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 5 HEALTHY LIVES Mortality Amenable to Health Care Deaths per 100,000 population* 1997–98 150 2006–07 134 127 116 115 109 99 100 89 88 120 113 106 97 97 88 81 76 50 96 57 55 61 60 61 64 66 74 67 76 79 78 77 80 83 d De nm Un ar ite k d Ki ng do Un m ite d St at es al an d Ze la n Ne w Ir e ec e Gr e m an y d Ge r Fi nl an No rw ay Ne th er la nd s Au st ria en Sw ed pa n Ja ly It a ra lia Au st Fr an ce 0 * Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. See Appendix B for list of all conditions considered amenable to health care in the analysis. Data: E. Nolte, RAND Europe, and M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files and CDC mortality data for U.S. (Nolte and McKee, 2011). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 6 HEALTHY LIVES Infant Mortality Rate Infant deaths per 1,000 live births National average and state distribution U.S. average 12 Top 10% states 11.1 10.3 8 Bottom 10% states 7.2 7.0 International comparison, 2007 10.8 10.2 9.9 9.9 9.6 6.9 7.0 6.8 6.8 10.1 6.8 10.0 9.9 6.9 6.7 6.8 6.8 5.1 4 5.3 5.1 4.0 5.0 4.9 4.8 4.7 4.7 5.0 5.0 5.0 2.0 2.5 2.6 2.7 3.1 20 07 20 06 20 05 ^ 20 04 20 03 ^ 20 02 20 01 20 00 19 99 19 98 0 n d de la n e e w Ic S n d rk ay da es pa lan rw ma na tat n Ja n o a i S F N C d De ite Un ^ Denotes years in 2006 and 2008 National Scorecards. Data: National and state—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003–2008; Mathews and MacDorman, 2011); international comparison—OECD Health Data 2011 (database), Version 06/2011. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 7 QUALITY: EFFECTIVE CARE Hospitals: Prevention of Surgical Complications Percent of adult surgical patients who received appropriate care to prevent complications* 2004 98 100 87 2006 97 93 2009 96 94 89 83 81 74 71 75 90 66 59 49 50 25 0 90th % ile 75th % ile Median 25th % ile 10th % ile * See Appendix B for methods and description of clinical indicators. Data: IPRO analysis of data from CMS Hospital Compare. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 8 QUALITY: COORDINATED CARE Medications Reviewed When Discharged from the Hospital, Among Sicker Adults, 2008 Percent of hospitalized patients with new prescription who reported prior medications were reviewed at discharge 100 77 75 67 54 57 59 59 59 60 FRA CAN NETH UK AUS 50 25 0 NZ US GER Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized or had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom; US=United States. Data: 2008 Commonwealth Fund International Health Policy Survey. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 9 QUALITY: SAFE CARE Potentially Preventable Adverse Events and Complications of Care in Hospitals Adjusted rate per 1,000 discharges* 2002 2003 2004 2005 2006 2007 Failure to rescue 141.7 135.0 128.9 120.4 114.0 105.7 Decubitus ulcers 22.1 23.4 24.7 24.1 24.6 25.1 Selected infections because of medical care 2.3 2.3 2.3 2.3 2.2 2.0 Postoperative pulmonary embolus or deep vein thrombosis 9.6 10.3 10.7 10.7 11.2 11.5 Postoperative sepsis 11.1 11.7 13.2 13.7 15.1 15.4 * Rates are adjusted by age, gender, age-gender interactions, comorbidities, and Diagnosis Related Group (DRG) clusters. Data: Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (retrieved from HCUPNet at http://hcupnet.ahrq.gov). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 10 10 QUALITY: PATIENT-CENTERED, TIMELY CARE Difficulty Getting Care After Hours Without Going to the Emergency Room, Among Sicker Adults, 2008 Percent of adults who sought care reported “very” or “somewhat” difficult to get care on nights, weekends, or holidays without going to the emergency room 100 75 56 58 59 59 CAN US AUS FRA 45 50 34 39 27 25 0 NETH GER NZ UK Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized or had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom; US=United States. Data: 2008 Commonwealth Fund International Health Policy Survey. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 11 Our Challenges • Structural challenges in this time of reform • Health needs and challenges in the populations we serve • Managing the complexity in caring for patients Figure 1. Growth in the Number of People Age 65 and Older 450 404 Number (in millions) 400 377 325 300 227 200 50 0 12% 249 250 100 300 281 203 10% 179 150 76 92 4% 96% 1900 106 4% 96% 1910 123 5% 95% 1920 132 5% 95% 1930 20% 351 65+ Under 65 350 151 7% 93% 1940 11% 13% 21% 17% 20% 13% 9% 8% 92% 1950 91% 1960 90% 1970 89% 1980 87% 1990 88% 2000 87% 2010 84% 2020 80% 2030 79% 2040 80% 2050 Note: The total population data for 1900 to 2000 include unknown age data. Therefore, the data used to determine the proportion of the population under age 65 and age 65 and older does not sum to equal the total population. Sources: 1900 to 2000 data are from Hobbs, F., & Stoops, N. (2002). Demographic Trends in the 20th Century (Census 2000 Special Reports, CENSR-4). Washington, DC: U.S. Census Bureau. Available at http://www.census.gov/prod/2002pubs/censr-4.pdf. 2010 to 2050 data are from Population Projections Program (2000). Projections of the Resident Population by Age, Sex, Race, and Hispanic Origin: 1999 to 2100 (Middle Series). Washington, DC: U.S. Census Bureau. Available at http://www.census.gov/population/www/projections/natdet.html. Source: R. Friedland and L. Summer, Demography Is Not Destiny, Revisited, The Commonwealth Fund, March 2005. THE COMMONWEALTH FUND A Youth Bulge • The world is in a demographic transition – from high rates of fertility and mortality, to lower birthrates and longer lives. • But since mortality rates are falling before fertility rates are, a “youth bulge” results. • We need new designs to ensure the health of these growing populations. Southcentral Foundation, Anchorage, AK The “Five Year Gestation” Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20% Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% Source: Behavioral Risk Factor Surveillance System, CDC. 25%–29% ≥30% Obesity Trends* Among U.S. Adults BRFSS, 2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% Source: Behavioral Risk Factor Surveillance System, CDC. 25%–29% ≥30% The “Hot Spots” • “Super” utilizers of health services • 5% of patients account for 49% of US health spending • Patients at the end of life need improved palliative and hospice care Our Challenges • Structural challenges in this time of reform • Health needs and challenges in the populations we serve • Managing the complexity in caring for patients Increasing Complexity • In the mid 1970s, the average patient in a hospital required 2.5 staff FTEs for care… • …20 years later, the average patient needs 19.5 FTEs† • A physician today has over 13,600 possible diagnostic options and the opportunity to select from over 6000 prescription options in the US †Source: Atul Gawande, MD The Path Forward • New ways to lead • Vibrant and important aims • More ways to learn The Four Leadership Questions • Do you know how good you are? • Do you know where you stand relative to the best? • Do you know where the variation exists? • Do you know the rate of improvement over time? New Leadership Skills Personal Structural Leading Through: • Attention • Listening • Sensing • Learning • Action • Signs and symbols Leading With: • Patient-led design • Structural huddles • Gemba walks • Cultural changes – – – – • • Safety Harm Patient-centered Improvement and innovation Spread strategy Building capability Structured Huddles • A huddle is a “communication vehicle…a fast, focused, highly collaborative process.”† • Huddles should be frequent and short. • They enhance communication; generate and help manage knowledge; and help continuously improve care delivery. Robert L. Meara, ME. “The Organizational Huddle Process – Optimum Results Through Collaboration.” Health Care Manager: December 2002. †Cooper, Huddles at Cincinnati Children’s Hospital Medical Center Gemba Walks Ghana: Rapid scale-up of systems improvement across nation’s health facilities Project is ahead of schedule, with simultaneous spread in northern regions (NCHS and Ghana Health Service) and middle regions (NCHS hospitals Collaborative). The Path Forward • New ways to lead • Vibrant and important aims • More ways to learn Health of a Population Experience of Care Per Capita Cost Health of a Population Experience of Care Per Capita Cost Institute of Medicine’s Six Aims • Safe – no needless deaths • Effective – no needless pain or suffering • Patient-Centered – no helplessness in those served or serving • Timely – no unwanted waiting • Efficient – no waste • Equitable – for all Patient-Centered Flow • Patient demand is growing • Our ability to safely and efficiently serve all patients depends on: – Right Patient – Right Place – Right Time – Right Care Team – No Delays • Most activity in the hospital is scheduled; urgent/emergent work is “predictable” Flow and Safety • Inseparable initiatives in a hospital • Getting the “Rights” right – Right Bed, Nursing Care, Time, Plan, Treatment • No longer a passive system – best care requires active management of these critical aspects of the patients experience. • Best route to optimize the best care model is to control the variables in care delivery. Initial Results of Re-Design • Weekday Waiting Times – 28% reduction in spite of a 24% increase in case volume • Weekend Waiting Times – 34% reduction in spite of a 37% increase in case volume • Throughput increase of 4.8% = 1 OR room in a setting of 20 rooms • Overtime hours decreased by an estimated 57% between September 18, 2006 and the first week of January 2007. If OR operating costs are estimated at $250/room hour, then these savings are equivalent to $10,750/week, or $559,000 annually. • Overall growth sustained at ~7% / year for past two years, no additional operating rooms added Greater Production Capacity Through Flow and Patient Placement – What Has it Meant? • Has allowed for an additional 78 patients per day to be treated within our current bed capacity that would not have been possible under “pre-flow improvement processes • Improved flow and patient placement have allowed us to avoid the construction of 102 additional beds ($100+ million) that would have been required to meet today’s volume in our FY2002 workflow system Institute of Medicine’s Six Aims • Safe – no needless deaths • Effective – no needless pain or suffering • Patient-Centered – no helplessness in those served or serving • Timely – no unwanted waiting • Efficient – no waste • Equitable – for all How do we make care more patient centered? The Burden of the Illness Innovation: 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 selfdialysis 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.” Lessons to Date • From Britt Mari (nurse and innovator): ─Found courage to say “yes” in the patient’s face ─“We used the same training program as I use for new nurses.” ─“The patients are our partners in designing the unit, buying equipment, teaching, and planning.” Lessons to Date • From Ingrid (nurse): ─“I got the courage to change (after 40 years) because I saw the patients ‘lift up.’” ─“I moved from being a technical expert to a coach.” ─“The patients are so fit, always exercising while they treat.” Health of a Population Experience of Care Per Capita Cost Henry Ford Health System Total Harm-Associated Costs 2009* Harm Issue Pressure Ulcer stage 2 or higher Total Associated Costs $10,624,410 Coded Procedural Complication ICD9 (998-999.99) UTI using coded data and AHRQ definition. Glucose below 40 Coded Acute Renal failure $7,670,520 $5,662,895 $3,846,375 $2,665,680 Coded DVT/PE in both medical and surgical patients No Pulse Blue Alert Coded Medication issue Clostridium difficile infection Reported Fall with injury Bloodstream Infections using NHSN criteria Coded Pneumothorax using AHRQ definition SSI using NHSN criteria VAP using NHSN criteria $2,365,470 $1,535,808 $1,216,078 $824,544 $696,527 $640,000 $340,260 $280,000 $190,352 *Henry Ford Hospital Only Removing Waste • Dr. Patty Gabow at Denver Health, a safety-net system, introduced a waste reduction focus several years ago. • Her team has reduced expenses there by $71M, $30M in the last year – she said, “We’re getting good at getting better.” Waste Identification Tool http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/ HospitalInptWasteIDTool.htm http://www.ihi.org/IHI/Results/WhitePapers/HospitalInpatientWasteIDTool WhitePaper.htm Health of a Population Experience of Care Per Capita Cost Ideal Collaboration Between Patients and Providers • The greatest, untapped resource for improving health care is the knowledge, wisdom, and energy of the individuals, families, and communities who face challenging health issues in their every day lives. • People must be engaged as co-producers of health care for themselves and their communities, not merely as patients or consumers of services. • Local communities must retrieve their own historical, cultural, and religious traditions of health and healing, and bring those into dialogue with contemporary medical systems. -Bill Doherty University of Minnesota Jönköping County Obesity Initiative Walking bus School nurse Dentist Nutritionist Salutogenesis Aaron Antonovsky From the Latin “salus” which means health, and the Greek “genesis” which means origin. A “health-ease” instead of a “dis-ease” continuum The Path Forward • New ways to lead • Vibrant and important aims • More ways to learn Live Case Visits • Powerful tool for showing the gap between current performance and the best • Visitors study an exemplar’s (host’s) processes from the inside ─ Interview staff ─ Reflect on challenges they face at their home organizations, ask the hosts how they have overcome barriers to change Live Case Visits • Visitors regroup and plan their strategy for the return home • Visitors then meet with hosts at the end of the visit to reflect on what they observed, and how this informs their strategy for their organization • Hosts offer advice, guidance, and feedback on visitors’ strategy Live Case Visits IHI Open School IHI Open School Chapter Community 365 Chapters US Chapters in 46 states International Chapters in 50 countries IHI Open School Measures • 68,000 students and residents registered on IHI.org • 9,000 faculty and deans registered on IHI.org • 27,000 students and residents have completed an online course • 1,900 students and residents have earned their Certificate of Completion * Since the IHI Open School was created in September 2008 Celebrating Success in the UT System • • • • • Reliable processes with great tempo Physician engagement Multidisciplinary teamwork Financial connections Progress! Promising Improvements in the UT System • Improved patient access at MD-Anderson’s Neuro-Interventional Ultrasound (NIR) ─Average time to next appointment decreased from over 25 days to 1 day ─Available appointment slots increased from 38 to 55 Promising Improvements in the UT System • Decreasing duration of mechanical ventilation at Parkland Health and Hospital system ─Mean duration of mechanical ventilation in the MICU decreased from 6.1 days to 4.0 days ─Ventilator-associated pneumonia rate reduced by 52% Promising Improvements in the UT System • Reducing avoidable harm in the medical ICU at UT Southwestern University Hospitals Dallas ─Health care-associated infections (HAIs) fell from 63 in 2009; to 32 in 2010; and to 21 as of August, 2011 ─Patient falls with injury eliminated in MICU Thank You! Maureen Bisognano President and CEO Institute for Healthcare Improvement www.IHI.org info@ihi.org 617-301-4800