Practical Leadership for Improvement

Donald M. Berwick, MD

President Emeritus and Senior Fellow

Institute for Healthcare Improvement

Derek Feeley, DBA

President and CEO

Institute for Healthcare Improvement

4th Annual Middle East Forum on Quality

and Safety in Health Care

Doha, Qatar

May 13, 2016

Format

1. The basics

2. The basics applied (Stories for Scotland)

3. Radical Redesign

2

The Basic Elements

Aim

Method

3

Institute of Medicine – 1999 & 2001

44,000 – 98,000 Deaths per Year

6 AIMS FOR IMPROVEMENT • Safety • Effectiveness • Patient-Centeredness • Timeliness • Efficiency • Equity

Population

Health

Experience

of Care

Per Capita Cost

The Triple Aim

5

Waste Category Annual Estimates

6

Category Cost to US Healthcare (2011 $B)

Overtreatment $158 to $226 Failures to Coordinate Care $25 to $45

Failures in Care Delivery $102 to $154 Excess Administrative Costs $107 to $389 Excessive Health Care Prices $84 to $178

Fraud and Abuse $82 to $272

2011 Total Waste $558 to $1263

% of Total Spending 21% to 47% (MED = 34%) 6

Model I: Bad Apples

The

Problem

Quality

Frequency

Model I: Bad Apples

The

Problem

Quality

Frequency

“Reliance on Inspection to Improve”

The Cycle of Fear

Increase

Fear

Micromanage Kill the

Messenger

Filter the

Information

Some Consequences of Reliance on Inspection

“Measurement” Has Gone Wild

“Accountability” Everywhere

“Skin in the Game” for Patients

“Standardization”

“Markets”

10

Joy in Work: Physician Morale (Shanafelt, et al. Mayo Clinic Proceedings; 2015. 90: 1600-1613)

0% 20% 40% 60%

Burnout

Satisfaction

2014

2011

11

Source: The Commonwealth Fund/Kaiser Family Foundation

2015 National Survey of Primary Care Providers

The “Juran Trilogy” – Quality As a Strategy

Quality

Frequency

Control Invention

Improvement

The Wrong Way

Quality

Frequency

Control

Invention

Improvement

“The First Law of Improvement”

Every system is

perfectly designed to

achieve exactly the

results it gets.

Organizational Elements for Continual

Improvement

Strategy

Culture Technique

Organizational Elements for Continual

Improvement

Strategy

Culture Technique

External

Internal

Population

Health

Experience

of Care

Per Capita Cost

The Triple Aim

17

New Rules for Radical

Redesign in Health Care

IHI’s “Leadership Alliance”

Radical Redesign Principles – IHI Leadership

Alliance 1. Change the Balance of Power

2. Standardize What Makes Sense

3. Customize to the Individual

4. Promote Wellbeing

5. Create Joy in Work

6. Make It Easy

7. Move Knowledge, Not People

8. Collaborate/Cooperate

9. Assume Abundance

10. Return the Money

19

From To

Fragmented Payment Unified Budgets

Hospital as the Center Home as the Hub

Excellent Soloists High Performing Teams

Moving People Moving Knowledge

“What Is the Matter with You?” “What Matters to You?”

A Sense of Scarcity A Sense of Abundance

Where We Are Headed….

Organizational Elements for Continual

Improvement

Strategy

Culture Technique

Dr. Joseph M. Juran’s “Trilogy” 22

QUALITY

PLANNING

QUALITY

IMPROVEMENT

QUALITY

CONTROL

What does it mean?

Quality Planning: You develop a new process using the principles of reliability from the beginning.

Quality Control: You monitor the process to be certain that it is working as designed. Does it continue to deliver the outcome you want?

Quality Improvement: The process is not delivering the outcomes as designed so it must be improved.

23

Juran Trilogy 24

QUALITY CONTROL (DURING OPERATIONS)

0 0

40

20

CO

ST

OF

PO

OR

QU

ALIT

Y

Op

era

tio

ns

Be

gin

Chronic Waste (an opportunity for improvement)

TIME

LESSONS LEARNED

Sporadic Spike

Original Zone of Quality Control

New Zone of Quality Control

QUALITY

IMPROVEMENT

25

What are we trying to Accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

The Model for Improvement

Act Plan

Study Do

When you

combine

the three

questions

with the…

…the Model

for

Improvement. PDSA cycle,

you get… A Model for Learning and

Change Source: The Improvement Guide p. 10

The Sequence of Improvement

Sustaining improvements and Spreading changes to other locations

Developing a change

Implementing a change

Testing a change Act Plan

Study Do

Theory and Prediction

Test under a variety of conditions

Make part of routine operations

Repeated Use of the PDSA Cycle for Testing

Hunches Theories Ideas

Changes That Result in Improvement

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

Model for Improvement

Sequential building of knowledge

under a wide range of conditions

Spreading

AP D

S

A

P

D

S

AP

D S

A

P

D

S

APD

S

A

P

D

S

A P

DS

Sustaining the gains

Change Idea: Standardize Intra-operative

Temperature Control

AP D

S

A

P

D

S

AP

D S

A

P

D

S

APD

S

A

P

D

S

A P

DS

Organizing the OR team & equipment will achieve reliable temp control

99% Reliability

Cycle 1, Day 1: With 1 OR team, assign responsibility for temp monitoring

Cycle 2, Day 2: Checklist and stocking process for warming devices in OR

Cycle 6: Educate staff on new standards

Cycle 5: Standardize and document devices and protocol

Percent of Surgeries with Intraoperative Temp

Control

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Obs

Percent

Daily % cases in control

12

3

4

56

Mini-measure tracks improvement cycles

Cycle 3, Day 3: 1st OR is reliable; test with 3 ORs and surgery types

Cycle 4: Analyze failures, test variation for selected surgical type

Monitor Temp

Stock supplies

Control Ambient Temp

Recovery Transfer

Working in Parallel on Multiple Change Ideas or

Drivers

A P

DS

A

P

D

S

APD

S

AP

DS

A P

DS

A

P

D

S

APD

S

AP

DS

A P

DS

A

P

D

S

APD

SA

P

DS

A P

DS

A

P

D

S

APD

S

AP

DS

Organizational Elements for Continual

Improvement

Strategy

Culture Technique

PULL

PUSH

1. Set Direction: 100% or Zero

Make the status quo uncomfortable

Make the future attractive

3. Build Will• Involve patients and families

• Understand the gap between

your current performance, the

best in class and the

theoretical ideal

• Use stories and data

• Go transparent

• Show courage

5. Execute Change• Establish accountability for

results

• Establish good oversight

process on “are we achieving

our aims?”

•Watch your own dots

•Weekly or monthly data

•25% Board time on quality

4. Generate Ideas• Read and Scan Widely, Learn

from other Industries &

Disciplines

• Benchmark to Find Ideas

• Listen to Customers

• Invest in Research &

Development

• Manage Knowledge

• Understand Organization as a

System

2. Establish the Foundation

• Quality education standards

for board

• Build a board culture of

healthy conversations

with MEC and

administration

• Establish Quality Committee

• Bring knowledgeable quality

leaders onto the board

Framework: Leadership for Improvement

Breakthrough Series (6-18 months) 32

Select Topic (Develop Mission)

Planning Group

Develop Framework & Changes

Participants (10-100 Teams)

Prework

LS 1

P

S

A D

P

S

A D

LS 2

Supports

Email (listserv) Phone Conferences

Visits Assessments

Sponsors Monthly Team Reports

Expert Meeting

AP1 AP2

LS – Learning Session

AP – Action Period

*AP3 –continue

reporting data as

needed to document success

LS 3

Dissemination

Publications, Congress. etc. A D

P

S

AP3* Holding

the Gains

NHS Scotland Surgical Mortality

Ghana “Fives Alive” - Start Small, Scale Up

Rapidly with Change Package

Start-up: Months 1-8

Total Population:

Under 5 Population:

Nov 2007

Wave 1: Months 9-22

350,000

60,000

Jul 2008

Wave 2: Months 23-63

5 million

500,000

Sept 2009

Wave 1R: Months 58-89

11 million

1.7 million

Aug 2012

No of. QI Teams: 30 258 350 369 >1,046

Jan 2013

Wave 3: Months 24-89

11 million

1.7 million

Oct 2009

Wave 4: Months 63-89

22 million

3.3 million

*Referral project launch

41 Referral Teams

Overall Under 5 Mortality Rate – 132 Ghana

Hospitals

27.8% Decline

1.0

2.0

4.0

8.0

16.0

32.0

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

RRT & CPR Rate / 1000 Discharges

All HMC Facilities

CPR Code rate / 1000 dicharges median Code rate

QEWS go live on Paper format (HGH)

QEWS go live on Cerner for other HMC facilities

2.3

10.7

14.3

18.2 18.9

18.0

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

RRT Rate / 1000 Discharges

All HMC facilities

6.0

7.6

2.9

9.5

4.4

5.3

6.9

3.4 3.7

2.9

5.5

2.1

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

Code Rate /1000 discharges HGH - Adult

CPR Code rate / 1000 dicharges Adult Mdeian

QEWS go live in HGH

0.0 0.0 0.0 0.0 0.0 0.0 0.0

22.8

26.2 26.0

35.1

27.7

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

RRT Rate /1000 discharges HGH - Adult

RRT rate / 1000 dicharges Adult

QEWS go live in HGH

A Durable List of Elements… (from Paul Batalden – circa 1991)

Quality-Mindedness

Customer-Mindedness

Process-Mindedness

Employee-Mindedness

Supplier-Mindedness

Statistical-Mindedness

Continual Learning (PDSA)

Leadership

41

Deming’s “14 Points for Top Leaders” 42

Discussion Questions

• What method (or methods) of improvement do you see in

your organization?

• When you look at Deming’s 14 points, what are your

organizations strengths and weaknesses?

Practical Leadership for

Improvement

Scotland Case Study

@derekfeeleyihi

Derek Feeley President and CEO

Institute for Healthcare Improvement

Context

– 5 million people

– £12 billion

– 14 Health Boards

– 8 Support Boards

– Integrated delivery

– Moving towards social care integration

Multimorbidity is common in Scotland

More people have 2 or more conditions than only have 1

A burning platform

No shortage of analysis

Policy Options

Do what we’ve always done

Let’s get more data

Run a pilot project

Run a campaign

Let Boards and hospitals decide what to do

Run a mandatory national improvement programme

Policy Risks – do nothing (new)

We’ll always get what we always got.

There will continue to be avoidable harm (even more perhaps as care gets more complex).

The debate continues to be about reporting rather than improving.

Its not denial, I am just selective about the reality I accept. - Bill Waterson

Approach

“By what method?... only the method counts” W Edwards Deming

Our previous approach

DESIGN DESIGN DESIGN DESIGN APPROVE

Conference Room

Real World

Previously….

IMPLEMENT

DESIGN

TEST & MODIFY

TEST & MODIFY

APPROVE IF NECESSARY

Conference Room

Real World TEST &

MODIFY

The Quality Improvement Way

START TO IMPLEMENT

We started to build

Execution

Ideas

Will

Path

We started in all acute hospitals

SPSP Outcome Aim Set in 2008

• Mortality aim amended to 20% by 2015

Mortality: 15%

reduction

• Ventilator Associated Pneumonia

• Central Line Bloodstream Infection • Blood Sugars w/in Range (ITU/HDU)

• MRSA Bloodstream Infection

• Crash Calls

Adverse Events: 30%

reduction

To be achieved across the nation by 2012

The SPSP Journey….

Compelling

vision

Common

goal

- aim high

Evidence-based

interventions

Model for

Improvement Knowledge & skills

Collaboration

Our change theory

A clear and stretch goal

A method

Predictive, iterative testing

Results

NHSScotland Surgical Safety Briefings

NHSScotland Surgical Mortality

NHSScotland Hospital Standardised Mortality Ratio

October 2006 to March 2015

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Jan

09

Ap

r 0

9

Jul 0

9

Oct

09

Jan

10

Ap

r 1

0

Jul 1

0

Oct

10

Jan

11

Ap

r 1

1

Jul 1

1

Oct

11

Jan

12

Ap

r 1

2

Jul 1

2

Oct

12

Jan

13

Ap

r 1

3

Jul 1

3

Oct

13

Jan

14

Ap

r 1

4

Jul 1

4

Oct

14

Jan

15

Ap

r 1

5

% M

ort

ali

ty

Mean 1: 33.7%

Mean 2: 29.1%

Mean 3: 23.3%

29.1% to 23.3% = 19.9%

reduction

from launch of Collaborative

% 30 day Mortality of ICD 10 A40/A41

Quarterly rates of Clostridium difficile per

100,000 bed days (65+, 15-64 and 15+)

Source: Health Protection Scotland

82% reduction in c-diff

cases in the over-65s since

2007

General Medical Services

Pharmacy

Community Nursing

Dentistry

Scale and Spread

“Up to 70% of improvement projects never spread.”

Eccles R, Miller Perkins K, Serafeim G. How to Become a Sustainable Company. MIT Sloan Management Review 2012;

53(4): 43-50.

What influences spread?

UK National School for Government 2006

Evidence

Experience & Expertise

Judgment

Resources

Values Habits & Traditions

Lobbyists & Pressure Groups

Pragmatics & Contingencies

Planning for Spread

Preparing for spread

Establishing an aim for

spread

Developing an initial

spread plan

Executing and refining the spread

plan

“In Scotland the spread plan was to start with all, just not with everything, everywhere. We told hospitals to start where they were

good and to get to complete coverage in 2 years.”

Executive mandate

Emergency mobilization

Extension agency

Breakthrough Series Collaborative model

Campaign model

Fishbowl

Commercialization

Grassroots organizing (one-to-ones)

“Wedge and spread” (wave sequence)

“Broad and narrow”

And many more…

Methods for Spread

A Learning System for Getting to Full Scale

Set-up

Build Scalable Unit

Test Scale- Up

Go to Full-Scale

Phases of Scale-

up

Best Practice

exists

New Scale-up

Idea Adoption

Mechanisms

Support Systems

Leadership, communication, social networks, culture of urgency and persistence

Learning systems, data systems, infrastructure for scale-up, human capacity for scale-up, capability for scale-up,

sustainability

Typical v. Exceptional

Typical Exceptional

They invest in comprehensive strategy

development.

They have a bias toward starting.

They have general goals for adoption. They have explicit national and local aims.

(Aim Primacy)

Leadership creates standards. Leadership removes barriers.

They have “theory lock.” Improvisation is a virtue.

Data is for assessment. Data is for rapid adjustment.

Safety as a System Property?

Thought you all may like to know that we have eradicated CLABSI within our ICU & deem it to be like polio or smallpox, namely a disease of the past (see the photo). VAP still a challenge where we hit the 300 day target but we always get one as a rare event. Whole team at the RAH quite proud & rightfully so in my eyes.

Kevin Rooney

Quality

Aims:

To deliver the highest

quality healthcare

services to the people of

Scotland

For NHSScotland to be

recognised as world-

leading in the quality of

healthcare it provides

“Safe, effective and

person-centred

care which supports

people to live as

long as possible at

home or in a homely

setting.”

3 Quality Ambitions

No avoidable injury or harm from the healthcare they receive, and

that they are cared for in an appropriate, clean and safe

environment at all times.

The most appropriate treatments, interventions,

support and services will be provided at the right time to

everyone who will benefit, with no wasteful or harmful

variation.

Person & Family-Centered Care

Experienced coordination gaps in past two years

1720 23

3036 37 39 40 42 43

53 56

0

10

20

30

40

50

60

70

80

90

100

SCO

rUK

SW

IZ NZ

AUS

NETH

SW

ECAN

US

NOR

FR

GER

Charts from 2011 Commonwealth Fund Survey of Sicker Adults

Person & Family-Centered Care

Person & Family-Centered Care

Quality Strategy built around patient priorities

Person Centered Care collaborative

Self management programme

From: “What’s the matter?”

To: “What matters to you?”

Kendra 7 year old Severe autism

Kendra

Changing

culture

NEW PUBLIC

MANAGEMENT

Targets,

sanctions,

inspections

QUALITY

IMPROVEMENT

MOBILISING

SOCIAL ACTION Ou

tco

mes

Time

Getting to the Third Curve

Sharing power

Keeping power

Ceding power

PERFORMANCE MANAGEMENT

QUALITY IMPROVEMENT

CO-PRODUCTION

The six questions to be asked of EVERY change programme…

1 Aim

Is there an agreed aim that is understood by everyone in the system?

2 Correct changes

Are we using our full knowledge to identify the right changes & prioritising those that are likely to have the biggest impact on our aim?

3 Clear change method

Does everyone know and understand the method(s) we will use to improve?

4 Measurement

Can we measure and report progress on our improvement aim?

5 Capacity and capability

Are people and other resources deployed and being developed in the best way to enable improvement?

6 Spread plan

Have we set out our plans for innovating, testing, implementing and sharing new learning to spread the improvement everywhere?

What worked for the point of care staff?

Get goals

Get bold

Get together

Get a method (and stick with it)

Get patients and families

Get the facts

Get to the field

Get a clock

Get the numbers

Get the stories

“The Scottish Patient Safety Programme

marks Scotland as leader,

second to no nation on earth,

in its commitment to reducing

harm to patients

dramatically and continually.”

Donald M Berwick

Discussion Questions

• What do you think were the keys to success in Scotland

and what could they have done differently (and better)?

• What elements of the Scottish approach might work in

your system?

New Rules for Radical

Redesign in Health Care

IHI’s “Leadership Alliance”

Radical Redesign Principles –

IHI Leadership Alliance

1. Change the Balance of Power

2. Standardize What Makes Sense

3. Customize to the Individual

4. Promote Wellbeing

5. Create Joy in Work

6. Make It Easy

7. Move Knowledge, Not People

8. Collaborate/Cooperate

9. Assume Abundance

10. Return the Money

Alaska Native People Shaping Health Care • SCF - 2011 Baldrige Winner • CEO 2004 McArthur Genius Winner

Copyright © 2011 Southcentral Foundation. All Rights Reserved. NOTICE: Unless otherwise indicated, this work represents copyrighted material protected by United States and international law. This work may not be used, reproduced, downloaded, disseminated, published, transferred or transmitted, in whole or in part, in any form or by any means, electronic or mechanical, including photocopying, recording or information storage and retrieval, except with the express written permission of the publisher. This work may not be edited, altered, or otherwise modified, in whole or in part, except with the express written permission of the publisher.

Design: Cooperate

“NUKA” CARE SYSTEM

Southcentral Foundation

Anchorage, Alaska, USA

Some Nuka Results

• Urgent Care and ER Utilization = 50%

• Hospital Admissions = 53%

• Specialist Utilization = 65%

• Primary Care Utilization = 20%

• HEDIS Outcomes and Quality = 75-90%ile

• Employee Turnover Rate < 12% per year

• Customer and Staff Satisfaction > 90%

$144,258,912

$-

$20,000,000

$40,000,000

$60,000,000

$80,000,000

$100,000,000

$120,000,000

$140,000,000

$160,000,000

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RIE + Blackbelt Combined Total Financial Benefit Trend Cumulative Through December 31, 2011 Design: Standardize What Makes Sense

Denver Health

Lean Production Results:

$180 Million Saved

105

Denver Health

Outcomes: #1 IN UHC

NEJM : 364: 23, June 9-2011, Arora S, Thornton K, Murata G

Design: Move Knowledge, Not People

Project ECHO

Project ECHO

ECHO Treatment Outcomes:

Equal to University Medical Center

Hepatitis C Outcome ECHO UNMH P-value

N=261 N=146

Minority 68% 49% P<0.01

SVR (Cure) Genotype 1 50% 46% NS

SVR (Cure) Genotype 2/3 70% 71% NS

SVR=sustained viral response

Arora S, Thornton K, Murata G. NEJM 2011; 364:23

Project ECHO

PEEK:

Telemedicine

at Scale

Design: Move Knowledge, Not People

PEEK: 10,000

Children Screened

per Week by

Teachers in Kenya

Design: Assume Abundance

DHAT Program:

Could Meet All Dental Health

Needs in Alaska’s Villages

with 70 DHAT’s

Alaska Dental Health AideTherapists - “DHAT” 111

Design: Assume Abundance

Introducing Christian

The Old Way

• Ryhov Hospital, Jönköping, Sweden had traditional

hemodialysis and peritoneal dialysis center.

• In 2005, a patient, Christian, asked about doing it himself.

Design: Change the Balance of Power

Co-Design of Dialysis Care

113

Patient Self-Care

114

How Far Can We Go?

115

Self-Dialysis

• Now 60% of Ryhov Hospital dialysis patients are

on self-dialysis

• Their aim: 75% of patients

Self-Dialysis Results

• Costs reduced 50%

• Complications dramatically reduced

• Measuring success by “number of patients

working”

420 Students:

20% of pupils in deciles 1-3

35% of pupils in deciles 4-7

45% of pupils in deciles 8 and 10

St Ninian’s Primary School Stirling, Scotland

At the Start:

45% of Pupils

Were Overweight

Design: Promote Wellbeing

“Fit to play, fit to learn”

St Ninians Primary School

Stirling Scotland

Ms Elaine Wyllie wylliee48s@stirling.gov.uk

“The Daily Mile”

Three years later,

and, of 57 Primary

One children, not

one is overweight

2. Understand unique impediments to joy

locally

3. Commit to share responsibility at all levels

4. Use validated approaches to improve joy

1. Ask providers “What Matters to you?”

Outcome: ↑ Patient experience

↑ Organizational performance

↓ Staff burnout

Design: Joy in Work

Design: Joy in Work

70%

80%

90%

100%

Ma

y-1

4

Ju

l-1

4

Se

p-1

4

Nov-1

4

Ja

n-1

5

Ma

r-15

Ma

y-1

5

Ju

l-1

5

Se

p-1

5

Nov-1

5

Ja

n-1

6

Ma

r-16

Ma

y-1

6

Ju

l-1

6

Se

p-1

6

Nov-1

6

Ja

n-1

7

Ma

r-17

Agree + Strongly agree

Radical Redesign (from the inside out)

Discussion Questions

• What radical redesign do you need in your system?

• What might be the redesign priorities?