Jeff Selberg Executive Vice President and COO Institute for Healthcare Improvement

1. Sustaining Visionary Leadership in Patient Safety and QualityImproving Health and the Value of Health Care Jeff Selberg Executive Vice President and COO Institute for Healthcare Improvement Washington State Hospital Association 79th Annual Meeting October 13, 2011

2. Philosophy We strive to improve health and health care by: • Motivating and building will for change with hope and optimism • Innovating and identifying new models of care • Ensuring the broadest possible adoption of leading practices through a philosophy of “All Teach All Learn.”

3. IHI Believes In: • Transparency • Improvement science • Effective leadership • Creating a safe and just environment for patients, families, and staff • Highly functioning teams • Patient centered care • Designing care with the patient involved…

4. What Outcome Are We Aiming For? To improve health and the value of health care.

5. Three Aims • Advancing Population Health • Improving Experience of Care • Controlling Per Capita Cost

6. Rising Expenditures

7. Cost and Population Health *Canadian Institute for Health Information, National Health Expenditure Trends, 1975-2010 **Human Resources and Skills Development Canada

8. Regional Infant Mortality Rates 2007

9. Life Expectancy at Birth (years), 2007

10. Regional Medicare 30 – Day Readmission Rates

11. Washington State Medicare Per Capita Payments 2008

12. Where are you in the Model Life Cycle? • Downward Pressures • Total Spend • Demographics • Consumer Unrest • Data • Systems Thinking • Response • Reduce Rates • Optimize Operations • Grow Volume for Efficiency • Develop More Efficient Clinical Processes Viability Adapted from The Second Curve, Ian Morrison 1996 Models

13. PrimaryDrivers Secondary Drivers

14. Medicare Payment Policy – Affordable Care Act Viability Adapted from The Second Curve, Ian Morrison 1996 Models

15. Fee For Service – Paying for Value (Incentive?) PrimaryDrivers Secondary Drivers

16. A Success Story (Sort Of?) Intermountain Healthcare

17. What Intermountain Learned • Most hospital admissions for a specific treatment had similar characteristics • In contrast, Intermountain found massive variation in physicians’ practices • Declines in variation were associated with large declines in costs, and clinical outcome quality remained Source: James B. Savitz L. “How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts.” Health Affairs. June 2011. 30:6

18. An Example • Dr. Alan Morris led a project to smooth out variation in ventilator settings for patients with acute respiratory distress syndrome at LDS Hospital. • Dr. Morris blended an evidence-based clinical guideline into the flow of work (checklists, order sets, clinical flow sheets) to make it a normative default. • In a group of the most acutely ill patients, the rate of guideline variances went from 59 percent to 6 percent; patient survival went from 9.5 percent to 44 percent; physicians’ time commitment fell by half; and the total cost of care was reduced by 25 percent. Source: James B. Savitz L. “How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts.” Health Affairs. June 2011. 30:6

19. But, IHS Lost Money For Their Efforts “…providers today are paid precisely for those care delivery episodes that quality improvement seeks to reduce. As we improved, the resources to drive further change disappeared.” Source: James B. Savitz L. “How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts.” Health Affairs. June 2011. 30:6

20. Transforming the Delivery SystemIs Payment Reform the Basis of 2nd Curve Innovation?

21. Goals of Payment Reform Miller, Harold. How to Create Accountable Care Organizations, 2009

22. Accountable Care Organizations Miller, Harold. How to Create Accountable Care Organizations, 2009

23. Better Care for Individuals • Better Health for Populations • Lower Per Capita Costs

24. Are you on the 2nd Curve? • Upward Pressure • Data Variability • Demographics – Chronic Disease • Appreciation for a System – Clinical Process • ACO Viability • Response • Political Pressures (Lobbying) • Market Consolidation • Emerging Models: ACO • Public Confidence (?) Adapted from The Second Curve, Ian Morrison 1996 Models

25. Elephant in the Room Is this really innovative? i.e. Kaiser Permanente Geisinger Health System

26. Kaiser Permanente

27. Why Isn’t This Model Scaling? • Public perception about systems of care? • Physicians and group practice? • Payers?

28. Where are you on the 2nd Curve? Viability Inflection Point Transition Adapted from The Second Curve, Ian Morrison 1996 Models

29. Will Changes in Payment Methods Force Changes in Structure and Systems? Process Structure Outcomes Improvement Science Hoffer-Gittlell, Heller School Brandeis University

30. …With Improvement Science Building the Evidence Base Over Time Structure Process Outcomes Relational coordination Shared goals Shared knowledge Mutual respect Frequent communication Timely communication Accurate communication Problem-solving comm Organizational performance Organizational structures Improvement Science Goldmann& Parry, Improvement Science, 2011 Gittell, Edmondson& Schein. Learning to Coordinate, 2011 Relational intervention Psychological safety Relationship mapping Perspective taking Role modeling Process improvement intervention Data gathering/analysis Process mapping Structured problem solving

31. Is the 3rd Curve real? • Upward Pressure • Cost effective • Customized • Minimally invasive • Integrated into living • Technology • Response • Patients are not smart/responsible enough • No supporting infrastructure • No business Model Viability Inflection Point Transition Adapted from The Second Curve, Ian Morrison 1996 Models

32. Disruptive Innovation

33. Centralization followed by decentralization in computing Jason Hwang, Innosight

34. The decentralization that follows centralization is only beginning in health care Specialty care Laboratory services Imaging services Clinical research and training Data collection and warehousing Surgical suites Jason Hwang, Innosight

35. A new ecosystem of disruptive business models must arise Telehealth / e-visits Wellness programs Worksite clinics Telecommunications Hospital at home Mobile care services Automated kiosks Wireless health devices Precision diagnostics Home monitoring Information management and decision-making tools Retail clinics Services while traveling abroad Home visits Medical homes and care teams Jason Hwang, Innosight

36. Simplifying technologies enable disruption by making work less dependent upon trial-and-error experimentation Intuitive, trial-and-error problem- solving Probabilistic Pattern Recognition Rules-Based • Infectious Ds • Oncology • Immunology Intuitive Medicine Empirical Medicine Precision Medicine • Infectious Ds • Oncology • Immunology Evidence-based medicine Imaging & molecular diagnostics Jason Hwang, Innosight

37. The Patient’s Health RecordCloud Infrastructure Fitness Center Home Telemetry Financial Services Grocery Store Pharmacy Home Health Care Primary Care Long Term Care Specialist Hospitals

38. MIT Media Lab John Moore, M.D. The doctor-patient relationship is deteriorating. Today’s information technology solutions are exacerbating the problem by perpetuating paternalistic decision-making and episodic care. CollaboRhythm is a technology platform that enables a new paradigm of healthcare delivery; one where patients are empowered to become active participants and where doctors and other health professionals are transformed into real-time coaches. We believe that this radical shift in thinking is necessary to dramatically reduce healthcare costs, increase quality, and improve health outcomes.

39. The True Disruptors Christian Gilbert

40. Health and Mortality

41. How do you lead in this environment?

42. References

43. The Tasks of Leadership • Envisioning Goals • Affirming Values • Motivating • Managing • Maintaining Unity • Explaining • Serving as a Symbol Gardner, The Tasks of Leadership

44. The Work of LeadershipTechnical vs. Adaptive Challenges • Technical – Problems solved through the knowledge of experts • Adaptive – Molding beliefs and behaviors. The solutions rest in the people themselves. “Learn your way through it.” Heifitz and Laurie, The Work of Leadership

45. Where are you in the Model Life Cycle? Optimizing the Current Model • Technical Leadership: • Problem solving through expertise Viability Transforming the Organization • Adaptive Leadership • New beliefs & behaviors • New relationships • New customers Adapted from The Second Curve, Ian Morrison 1996 Models

46. The Wise LeaderPractical Wisdom …is tacit knowledge acquired from experience that enables people to make prudent judgments and take actions guided by values and morals. Nonaka and Takeuchi, The Wise Leader

47. Practical Wisdom Or, common sense to an uncommon degree! Nonaka and Takeuchi, The Wise Leader

48. The Wise LeaderPractical Wisdom Explicit knowledge codified, measured, and generalized …placed in the context of people’s goals, values, and interests Nonaka and Takeuchi, The Wise Leader

49. The Wise LeaderPractical Wisdom “No company will survive over the long run if it does not offer value to customers, create a future that rivals can’t, and maintain the common good.” Nonaka and Takeuchi, The Wise Leader

50. The Wise Leader Is A Philosopher A Master Craftsman An Idealist A Politician A Novelist A Teacher Nonaka and Takeuchi, The Wise Leader