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May 23, 2013. Denver Medical Study Group. Jeff Selberg Executive Vice President and COO. Connecting Health and Health Care. From n=1 to n=7 x 10 9. Overview. Institute for Healthcare Improvement Overview What Problem Are We Trying To Solve? Disruptive Innovation

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connecting health and health care
May 23, 2013

Denver Medical Study Group

Jeff Selberg

Executive Vice President and COO

Connecting Health and Health Care

From n=1 to n=7 x 109

overview
Overview
  • Institute for Healthcare Improvement Overview
  • What Problem Are We Trying To Solve?
  • Disruptive Innovation
  • Connecting Health and Health Care
  • Courageous Adaptive Leadership
ihi background
IHI Background
  • Founded by Don Berwick and colleagues
  • Current President and CEO: Maureen Bisognano
  • Grew out of National Demonstration Project on Quality Improvement in Health Care (NDP)
  • First National Forum was the NDP Summit
  • Incorporated in 1991
  • From 4 employees to now 135
  • Office in Cambridge, Massachusetts
  • Remote employees in many other locations
some of our groundbreaking initiatives are
Some of Our Groundbreaking Initiatives Are:
  • 100,000 and 5 Million Lives Campaigns
  • IHI Open School for Health Professions

135,581 students and residents, 578 chapters, 59 countries

  • The IHI Triple Aim
  • The Improvement Map & Passport
  • STAAR (STate Action on Avoidable Rehospitalizations)
  • Safer Patients Initiative (UK)
  • Scottish Patient Safety Programme
  • Chronic Care Initiative (Indian Health Service)
  • WIHI
slide6

Our MissionTo improve health and health care worldwide.

Our Vision

Everyone has the best care and health possible.

Who We Are

IHI is a leading innovator in health and health care improvement worldwide, joining forces with the IHI community to spark bold, inventive ways to improve the health of individuals and populations.

What We Want to Accomplish

Together with our ever-growing community of visionaries, leaders and frontline practitioners around the world, we seek and achieve vital science-based improvements in health and health care.

How We Work (Will, Ideas, Execution)

With the IHI community, we motivate and build the will for change, identify and test innovative models of care, and ensure the broadest possible adoption of proven practices that improve individual and population health.

Where We Work

We work globally because countries are interdependent in terms of health and health care, innovations can arise anywhere, and everyone has something to teach and something to learn.

the platform for improvement
The Platform for Improvement
  • Will, hope, and optimism
  • Transparency: All Teach – All Learn
  • Safe and just environment
  • Innovation and improvement science
  • Integrated results oriented teams
  • Designing care with the patient involved
  • Courageous adaptive leadership
five areas of focus
Five Areas of Focus
  • Improvement Capability
  • Patient Safety
  • Person- and Family-Centered Care
  • Quality, Cost, and Value
  • The Triple Aim for Populations
how we work
How We Work

Goal: Harvest, create, and test bold, innovative ideas and new models of care that support our strategic initiatives

Goal: Build reach and will to accelerate the pace of improvement worldwide

Goal: Leverage strategic partnerships and key initiatives to achieve ambitious improvement goals

Goal: Offer programming to transfer knowledge and build improvement capability

slide12

How will we know whether the approaches and the changes result in improvement?

Health Care Settings/Populations

Innovation

Testing

Spread & Scale up

Big Dot

Outcomes/Performance

US Neonatal Mortality

Related Dots*

Kirkpatrick Level

Process/Culture

Implementation of changes to reduce Neonatal Mortality

LearningKnowledge of improvement methods

ExperienceExcellent experience working with IHI

0

V?

W?

X?

Y?

Z?

*We will see change at levels 1 to 3 much sooner than at level 4

Time (years)

costs and affordability
Costs and Affordability

PROBLEM

  • $2.5 Trillion total spend in 2009
  • 17.6% of the GDP
  • Overspend estimated at $572 billion (ESAW) with 85% in outpatient services
  • Rate of growth slowing from 9.5% in 2002 to 3.9% in 2010.

Accounting for the Cost of U.S. health care, McKinsey&Company, December 2011

slide16

PROBLEM

Accounting for the Cost of U.S. health care, McKinsey&Company, December 2011

mortality amenable to health care

HEALTHY LIVES

Mortality Amenable to Health Care

Deaths per 100,000 population*

PROBLEM

* 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).

17

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

infant mortality rate 2007

HEALTHY LIVES

Infant Mortality Rate, 2007

PROBLEM

18

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

medical medication and lab errors among sicker adults 2008

QUALITY: SAFE CARE

19

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

EXHIBIT 16

Medical, Medication, and Lab Errors, Among Sicker Adults, 2008

Percent of adults reported medical mistake, medication error, or lab error in past two years

PROBLEM

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.

mckinsey commentary
McKinsey Commentary

“…the combination of a reimbursement system that pays for value over volume and a population of consumers that make value based buying decisions could drive improved performance within the system.”

“…it remains to be seen how quickly and effectively industry stakeholders will navigate the messy transition of incentives, behaviors, and business models.”

Accounting for the Cost of U.S. health care, McKinsey&Company, December 2011

affordable care act a summary
Affordable Care Act: A Summary
  • Restructure payments to Medicare Advantage (MA) plans
  • Reduce annual market basket updates for care and adjust for productivity
  • Establish an Independent Payment Advisory Board to propose recommendations for reducing per capita growth rates
  • Allow shared savings for Accountable Care Organizations
  • Create an Innovation Center within CMS
affordable care act a summary1
Affordable Care Act: A Summary
  • Reduce Medicare payments for readmissions and hospital acquired conditions
  • Reduce aggregate Medicaid DSH allotments
  • Establish national Medicare pilot program to develop and evaluate bundled payment
  • Create Independent at Home demonstration project for high-need beneficiaries
  • Establish hospital value-based purchasing program
  • Improve care coordination for dual eligibles
jason hwang m d m b a
Jason Hwang, M.D., M.B.A

The Innovator’s Prescription:

How Disruptive Innovation Can Fix Health Care

slide30

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

the r e e ngineered d ischarge reducing 30 day all cause rehospitalization rates

The ReEngineeredDischargeReducing 30 Day All Cause Rehospitalization Rates

Brian Jack, MD

Professor and Chair

Department of Family Medicine /

Boston University School of Medicine

Boston Medical Center

Faculty & Fellowship Seminar

Institute for Healthcare Improvement

Cambridge, MA 02138

March 11, 2013

using health it to overcome challenge of clinician time

Characters: Louise (L) and Elizabeth (R)

Using Health IT to Overcome Challenge of Clinician Time
  • Virtual Patient Advocates
    • Emulate face-to-face communication
    • Develop therapeutic alliance-empathy, gaze, posture, gesture
    • Teach AHCP
    • Tailored
    • Do “Teach Back”
    • Can drill down
    • Print Reports
    • High Risk Meds
    • Lovenox
    • Insulin
who would you rather receive discharge instructions from
Who Would You Rather Receive Discharge Instructions From?

36% prefer Louise

48% neutral

16% prefer doc or nurse

“I prefer Louise, she’s better than a doctor, she explains more, and doctors are always in a hurry.”

“It was just like a nurse, actually better, because sometimes a nurse just gives you the paper and says ‘Here you go.’ Elizabeth explains everything.”

1=definitely prefer doc, 4=neutral, 7=definitely prefer agent

twice as many pts prefer louise than rn md
Twice as Many Pts Prefer Louise than RN/MD

“It was just like a nurse, actually better, because sometimes a nurse just gives you the paper and says ‘Here you go.’ Louise explains everything.”

“I prefer Louise, she’s better than a doctor, she explains more, and doctors are always in a hurry.”

Bickmore TW, Jack B, et al. Journal of Health Communication 2010:15:197-210

slide37

Source: The Right to World Class Healthcare: A Model for Response to Health Crisis in Developing Countries,

Ernest C. Madu, MD, FACC, FRCP, April 2013

mit media lab john moore m d
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.

the patient s health record cloud infrastructure
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

where are you in the model life cycle
Where are you in the Model Life Cycle?

Viability

Optimizing the Current Model

  • Technical Leadership:
  • Problem solving through expertise

Transforming the Organization

Inflection Point

  • Adaptive Leadership
  • New beliefs & behaviors
  • New relationships
  • New customers

Adaptive Leadership

Technical

Leadership

Models

Adapted from: The Second Curve, I. Morrison, 1996

The Innovator’s Prescription, C. Christensen, 2008

Adaptive Design, J. Kenagy, 2009

slide42

The Health and Health Care Continuum

Alan Morris

Intensive Care

Optimal Functionality

Full Cycle of Care

Diagnosis

Hospital Care

Emory Orthopedic and

Spinal Hospital

(Clinical)

Total Health

Tony DiGioia

(Clinical + Social)

Hospital

  • Care Oregon
  • Kaiser Permanente

Long Term Care

Ambulatory

Social Service

Prevention

alan morris
Alan Morris

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

tony digioia
Tony DiGioia

Dr. Anthony M. DiGioia III, orthopedic surgeon and developer of the patient- and family-centered care program for UPMC, in his office at Magee-Womens Hospital in Oakland.

a case study from university of pittsburgh medical center upmc
A Case Study From University of Pittsburgh Medical Center (UPMC)

Aims in redesigning care for patients undergoing total joint replacement

Patient and family education

Less invasive techniques

Multimodal anesthesia and pain management techniques

Rapid rehabilitation protocols

Rapid outcomes feedback (from the patients’ and the providers’ perspectives

Creating a learning environment and culture

Developing a sense of community, competition and teamwork among patients and between patients, caregivers and staff

Promoting a wellness (rather than sickness) approach to recovery

DiGioia A, Greenhouse P, Levison T. “Patient and Family-centered Collaborative Care: An Orthopaedic Model”. Clinical Orthopaedics and Related Research. 2007: 463; pp: 13-19.

slide47

Better Care for Individuals

  • Better Health for Populations
  • Lower Per Capita Costs
where are you in the model life cycle1
Where are you in the Model Life Cycle?

Viability

Optimizing the Current Model

  • Technical Leadership:
  • Problem solving through expertise

Transforming the Organization

Inflection Point

  • Adaptive Leadership
  • New beliefs & behaviors
  • New relationships
  • New customers

Adaptive Leadership

Technical

Leadership

Models

Adapted from: The Second Curve, I. Morrison, 1996

The Innovator’s Prescription, C. Christensen, 2008

Adaptive Design, J. Kenagy, 2009

where are you in the model life cycle2
Where are you in the Model Life Cycle?

Transforming the Organization

Viability

  • Adaptive Leadership
  • New beliefs & behaviors
  • New relationships
  • New customers

Optimizing the Current Model

  • Technical Leadership:
  • Problem solving through expertise

Patient

Inflection Point

Adaptive Leadership

Technical

Leadership

Models

Adapted from: The Second Curve, I. Morrison, 1996

The Innovator’s Prescription, C. Christensen, 2008

Adaptive Design, J. Kenagy, 2009

the true disruptors
The True Disruptors

Christian

Gilbert

the four leadership questions
The Four Leadership Questions
  • Do you know how good your hospitals are?
  • Do you know where your hospitals stand relative to the best?
  • Do you know where the variation exists?
  • Do you know your hospital’s rate of improvement over time?
the four leadership questions1
The Four Leadership Questions
  • Do you know how good your community’s health is?
  • Do you know where you community stands relative to the best?
  • Do you know where the variation exists?
  • Do you know your community’s rate of improvement over time?
key elements for rapid improvement
Key Elements for Rapid Improvement
  • Executive leadership
  • Alignment with goals
  • Staff engagement
  • Improvement framework
  • Timely and reliable data
  • Deployment framework
  • Learning community
  • Performance based culture
leading is not tidy
Leading Is Not Tidy
  • Decisions are made and then reversed
  • Misunderstandings are frequent
  • Inconsistency is inevitable
  • Inside every solution are the needs of new problems
  • Most of the time most things are out of hand

Nonaka and Takeuchi, The Wise Leader

summary
Summary
  • Attention is the currency of leadership
  • Exercising leadership is risky and difficult
  • Articulating a vision begins with listening, dialogue, and diagnosing
  • A powerful source of learning better leadership is your/our own failures
  • One may lead perhaps with no more than a question in hand
  • Compliments of Heifetz

Adapted from Doug Bonacum

Vital Leadership Behaviors

role of the leader
Role of the Leader

“Servant of what is.”

And,

“shaper of what might be.”

Nonaka and Takeuchi, The Wise Leader

final thoughts
Final Thoughts
  • Get patients involved
  • Increase improvement capability
  • Focus on reducing harm
  • Build capability to design, adhere to, and refine models of care (full cycle)
  • Link Local Health System Performance with the IHI Triple Aim*

*Rising to the Challenge: Results from a Scorecard on Local Health System Performance, 2012, The Commonwealth Fund

http://www.commonwealthfund.org/Publications/Fund-Reports/2012/Mar/Local-Scorecard.aspx

in the end
In The End

…it’s all about improvement.