What We Can Learn From Others: The IHI experience with quality improvement around the world Kelly  McCutcheon  Adams,  LICSW  IHI  Director  

March 11, 2014

The Model for Improvement ! Results in many settings from improving education

outcomes to reducing infection ! It is what you do all day, everyday ! Making it more formal and planned ! Power of teamwork ! Power of measurement

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EXAMPLES

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James M. Anderson Center for Health Systems Excellence

Norwood Safety Days – May & September 2012

•  Two volunteers per home –  One volunteer as educator –  One volunteer as installer –  Install up to $90 in equipment (smoke/CO detector,

stair gate, window guards, cabinet locks, outlet covers)

James M. Anderson Center for Health Systems Excellence

Injury Reduction in Intervention Homes

0%

20%

40%

60%

80%

100%

Observed/Expected Injuries

All homes

Intevention Homes

Non-intervention

*

•  1150 Norwood Children Ages 1-4 We have reached 184 (16%) in 130 Homes

•  82% reduction in intervention homes •  Estimate that if intervention into 40% of

homes community reduction goal could be met

! Know the problem (vulnerability index) ! Employ housing first (wraparound services) ! Create easy-to-track, shared metrics ! Continuously improve core housing process

Simple, Shared Metric

Malawi “3 Delays”: Drivers of Maternal Mortality and Morbidity

Reduce  maternal  

mortality  and  morbidity  

2nd  Delay  -­‐  reaching  an  

appropriate  care  

1st  Delay  –  deciding  to  seek  appropriate  medical  help  AIM  

3rd  Delay  -­‐  receiving  

adequate  care  when  a  facility  is  

reached  

PRIMARY  DRIVERS  

Malawi: Women’s Groups

UCL

LCL

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20

30

40

50

60

Jan-

11

Mar

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May

-11

Jul-1

1

Sep

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Nov

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Jan-

12

Mar

-12

May

-12

Jul-1

2

Sep

-12

Nov

-12

Jan-

13

Mar

-13

May

-13

Rate   24h  OB  coverage  in  house  Nurse  mentoring  program  for  neonatal  intervenEons  

MaiKhanda  QI  team  reconsEtuted  Public  Audit  of  neonatal  deaths  

VLBW  to  KCH  ANCS  program    

Malawi    Neonatal  Mortality  per  1000  live  births  

First  8  months  of  2011:  348  deaths  Last  8  months:  202  deaths  

Outcome Primary Drivers Secondary Drivers

Reduce falls resulting in harm by 50% by March 2014

 

Risk identification

 

Multi-factorial risk assessment

 

• Patient specific falls risk assessment

-­‐ Falls history/medication review -­‐ Use of sedation -­‐ Gait balance, mobility, muscle

weakness -­‐ Osteoporosis risk -­‐ Functional ability

-­‐ Visual and cognitive impairment weighted highly in risk score

-­‐ Urinary incontinence -­‐ Cardiovascular assessment -

hazards -­‐ Environmental

Multi-factorial interventions  

 

• Care plans / care pathway developed following on from patient specific risk assessments

• Preparing the environment • Implement Intentional rounding • Establish clear delirium management pathway that acknowledges an

increased risk of falls  

 

Communication of falls risk status

 

• Communicate risk (who need to know) • Visual triggers • Involvement of patient and family • Integrate falls risks in ward handovers and safety briefings  

 

Education  of  staff,  patient  and  family/carer  

 

• Develop a clear falls prevention pack for patients and families • Falls prevention programme for staff  

 

• Understand local falls risk - where, when, time etc. • Early identification and assessment of risk at first point of entry into care  

 

South  of  England  Mental  Health  CollaboraDve  Falls  Driver  Diagram  

South  of  England  Mental  Health  CollaboraDve  Total  Falls  Across  the  CollaboraDve  

(15  hospitals)  

Note  that  the  variaEon  amongst  all  15  sites  has  

decreased  as  well  as  the  average  number  of  falls.  

13 Ghana: Fives Alive!

! Insert day’s agenda

Scottish Patient Safety Programme

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Critical care – SAB rate (per thousand bed days)

0

2

4

6

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10

12

Jan-08

Mar-08

May-08

Jul-08

Sep-08

Nov-08

Jan-09

Mar-09

May-09

Jul-09

Sep-09

Nov-09

Jan-10

Mar-10

May-10

Jul-10

Sep-10

Nov-10

Jan-11

Mar-11

May-11

Jul-11

1.785

0.38

79% reduction

STARR

Reducing Readmissions from Skilled Nursing Care Homes

TransiDon  from  Hospital  to  Home  • Enhanced  Assessment  

• Teaching  and  Learning  

• Real-­‐Eme  Handover  CommunicaEons  

• Follow-­‐up  Care  Arranged  

Post-­‐Acute  Care  AcDvated  • MD  Follow-­‐up  Visit  • Home  Health  Care  (as  needed)  

• Social  Services  (as  needed)  

• Skilled  Nursing  Facility  Services  

• Hospice/PalliaEve  Care  

Supplemental  Care  for  High-­‐Risk  PaDents  *  • TransiEonal  Care  Models  • Intensive  Care  Management  (e.g.  PaEent-­‐Centered  Medical  Homes,  HF  Clinics,  Evercare)  

or

IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations

* Additional Costs for these Services

Improved Transitions and Coordination of Care Reduction in Avoidable Rehospitalizations

PaDent  and  Family  Engagement  

Cross-­‐ConDnuum  Team  CollaboraDon  

Evidence-­‐based  Care  in  All  Clinical  SeKngs  

Health  InformaDon  Exchange  and  Shared  Care  Plans  

(c) Eric A. Coleman, MD, MPH

Key Elements of The Care Transitions Intervention®

l Adaptable to wide variety of care settings l One home visit, three phone calls over 30 days l  “Transition Coach” is the vehicle to build skills,

confidence and provide tools to support self-care –  Model behavior for how to handle common problems –  Practice or role-play next encounter or visit –  Elicit patient’s health related goal –  Create a “gold standard” medication list

(c) Eric A. Coleman, MD, MPH

Key Findings of The Care Transitions Intervention®

l Significant reduction in 30-day hospital readmits) l Significant reduction in 90-day and 180-day

readmits (sustained effect of coaching) l Net cost savings of $300,000 for 350 pts/12 mo l Adopted by over 580 leading health care

organizations in 39 states nationwide l Please visit www.caretransitions.org

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Looking at the map ! IHI Employees (there is a peg in the US for each remote

worker – and one peg for Cambridge) ! IHI Open School Chapters (there is one peg per country

that has at least one chapter – this does not indicate countries with more than one chapter)

! IHI Faculty (one peg per country with at least one faculty member)

! Grants and Contracts (one peg per country with at least one grant or contract)

! LoMIC (one peg per country where LoMIC works)

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IHI Staff photo

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Going Forward

“Make no little plans; they have no magic to stir men’s blood and probably will themselves not be realized. Make big plans; aim high in hope and work, remembering that a noble, logical diagram, once recorded will not die.” – Daniel Burnham

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