How Rural Hospitals Are Designing Excellent Care

1. How Rural Hospitals Are Designing Excellent Care Jeff Spade IHI Rural Affinity Group Leader Vice President, NCHA June 2008 jspade@ncha.org

2. Are rural hospitals leading and designing the care of the future? The Fundamental Question • Are rural health organizations leading or following? • How do the Hospital Compare metrics and IHI initiatives apply to rural hospitals? • What is the role of governing boards?

3. Concepts to Explore • Are Rural Hospitals Leading and Designing Excellent Care? • What Principles and Concepts are Key to Leading Performance in Care Excellence? • How Can We Further Engage Leadership? • Application, Challenge, Questions, Dialogue

4. Percentage of WA Hospitals in National Top 10%Heart Attack Washington rural hospitals outperformed urban hospitals on heart attack measures. Source: CMS, Hospital Compare, July 2006 - June 2007

5. Percentage of WA Hospitals in National Top 10%Heart Failure Washington rural hospitals outperformed urban hospitals on 3 of 4 measures. Source: CMS, Hospital Compare, July 2006 - June 2007

6. Percentage of WA Hospitals in National Top 10%Pneumonia Washington rural hospitals outperformed urban hospitals on 6 of 6*measures. * Does not include oxygenation assessment due to high compliance among all hospitals. Source: CMS, Hospital Compare, July 2006 - June 2007

7. Percentage of WA Hospitals in National Top 10%Surgical Site Washington rural hospitals outperformed urban hospitals on 4 of 5 measures. Source: CMS, Hospital Compare, July 2006 - June 2007

8. Eliminating Hospital Acquired Infections • 25% of hospital acquired infections, like MRSA can be prevented with hand hygiene “Best Hands on Care Award” – CEO Challenge For more information contact CarolW@wsha.org

9. Hand Hygiene Leaders As of June 5, 2008

10. Best Practice Cardiac Care in Rural Communities Lincoln Medical Center and many other rural communities. “Local care, best in the nation” For more information contact RandyB@wsha.org

11. Small Hospitals Adapting the Campaign St. Peter Community Hospital (CAH), St. Peter, MN Acute Myocardial Infarction care for inpatients became Emergency Department care and rapid transfer for Acute MI patients. Prevention of Adverse Drug Events became Medication Reconciliation and redesign of medication intake, transfer and discharge planning tools and processes. Rapid Response Teams to prevent acute cardiopulmonary collapse on the inpatient unit became Recognize, Respond and Treat: Promptly recognizing a decline in patient condition to decrease transfers to a higher level of care at another institution. Preventing central line sepsis became Preventing infections related to peripheral, pic and central lines. Preventing Surgical Site Infection was extended to Using clippers throughout the hospital including: ED, Med Surg, OB and Surgery. 11

12. Small Hospitals Adapting the Campaign St. Peter Community Hospital (CAH), St. Peter, MN RESULTS Rapid Response Team prevented 11 (28%) transfers to another hospital. The average savings per transfer was $6210. Reduced Acute Hospital Mortality Rate from 26/1000 to 10-12/1000. Intravenous line infections have disappeared. Surgical Site Infections have declined from 15.2/1000 to 7.0/1000. Medication Reconciliation improved from 76% to nearly 100%. 12

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14. Transylvania Community 81% performance

15. “If you’re going to be naked, you’d better be buff!”Don Tapscott and David TicollThe Naked Corporation Performance Improvement & Transparency

16. Leadership Characteristics • Driving Accountability for Performance • Designing and Delivering Reliable Care • Organizing and Actively Participating in Learning Collaboratives • Developing Organizational Competencies in Quality & Performance

17. Transparency and Reliability When hospitals’ quality data is reported publicly… • Performance improves (for the measures being reported). • Market share doesn’t change appreciably. • Reputation improves considerably. ACCOUNTABILITY Hibbard J, J Stockard, and M Tusler: Hospital performance reports: impact on quality, market share, and reputation. Health Affairs 2005, 24, #4: 1150-116025

20. Pneumonia Care

21. Transparency and Reliability A process achieves exactly the results it is designed to achieve.

22. Levels of Reliability in Health Care (Amalberti, Nolan)

23. Concentrate Your Work Here!

24. Starting Labels of Reliability • Chaotic process: Failure in greater than 20% of opportunities • 10-1: 80 or 90 percent success. 1 or 2 failures out of 10 opportunities • 10-2: 5 failures or less out of 100 opportunities • These are IHI definitions and are not meant to be the true mathematical equivalent.

25. NC Top 10% 115% Improvement

26. Concepts for 10-1 Performance • Common equipment, standard order sheets, multiple choice protocols, procedures & policies • Personal checklists • Feedback on compliance • Suggestions to work harder next time • Awareness and training • Intent, vigilance and hard work

27. Concepts for 10-2 Performance • Decision aids and built-in reminders. • Desired action is the default. • Redundant processes utilized. • Scheduling used in design development. • Habits and patterns known and included in design. • Standardization of processes based on clear specification and articulation of the norm. • Uses human factors and reliability science to design sophisticated failure prevention, identification and mitigation.

28. Is Our Glass Half Empty or Half Full?

29. Leadership Characteristics • Driving Accountability for Performance • Designing and Delivering Reliable Care • Organizing and Actively Participating in Learning Collaboratives • Developing Organizational Competencies in Quality & Performance

30. CAH & Rural Hospital Improvement Project • Based on CMS indicators for pneumonia and heart failure. • In partnership with NC Office of Rural Health, NCHA and CCME. • Commitment by 26 small, rural hospitals. • Utilizes an optimal care score to measure performance. • Workshops and collaborative learning along with performance reporting. • Considered a national model for CAHs.

31. Improvements Achieved By • Collaborative workgroups, coaching & mentoring, sharing resources. • Initial focus on pneumonia and heart failure, how to develop care processes. • Performance measurement is key. • Analyses and reports feature: • Inclusions and exclusions • Composite scores • CAH mean vs. NC benchmarks (top 90% performance) • Spider graphs to share with staff and board

32. “All-or-None” Measurement • Also Optimal Care or “perfect care”. • A more stringent outcome measure that reflects ability to manage care processes. • Completion of a full set or bundle of tasks. • Emphasizes system-wide improvement. • Appropriateness of care measures help to focus improvement efforts. • Indicative of organizational capacity to design reliable care processes.

33. Pneumonia Spider Graph

34. Pneumonia Care

35. NC Top 10% 115% Improvement

36. Heart Failure Care

37. NC Top 10% 50% Improvement

38. Combined Indicators

39. Pneumonia Care

40. Heart Failure Care

41. Leadership Characteristics • Driving Accountability for Performance • Designing and Delivering Reliable Care • Organizing and Actively Participating in Learning Collaboratives • Developing Organizational Competencies in Quality & Performance

42. Performance Improvement Primer • Patient Centered Care • Design for Reliability (zero defect rates) • Evidence-based Practice • Clinical Process Improvement (PDSA) • Rapid Cycle Improvement • Collaborative Learning and Spreading Innovations • Measurement and Segmentation (small tests of change) • Leadership Framework for Improvement • This is THE WORK of Healthcare Organizations and Professionals

43. Execution Step by Step 1. Setting Priorities and Breakthrough Performance Goals 2. Developing a Portfolio of Projects to Support the Goals 3. Deploying Resources to the Projects That Are Appropriate for the Aim 4. Establishing an Oversight and Learning System to Increase the Chance of Producing the Desired Change Execution of Strategic Improvement Initiatives IHI White Paper

44. Governance Attributes Significantly better quality outcomes are strongly related to five governance attributes: • Board spends more than 25% of its time on quality issues. • Board receives a formal quality measurement scorecard or dashboard. • High level of interaction between the board and the medical staff on quality strategy. • Senior executives’ compensation is based in part on QI performance. • CEO is identified as the person with the greatest impact on QI, especially when so identified by the QI executive.

45. Scorecards and Quality Performance • High performers are more likely to view board dashboards on a monthly basis (or more), whereas low performers are more likely to view them quarterly (or less). • Higher performance is associated with hospitals where the board quality committee and the QI staff are strongly involved with the development of dashboard content.

46. Scorecards and Quality Performance • Higher quality outcomes are associated with hospitals that use scorecards for more than just informational purposes. • Better performance is associated with hospitals that link scorecards to quality improvement projects, daily operations management and public performance. • Hospitals that have been using dashboards more than 2 years demonstrate higher quality than those with a shorter history of use.

47. Boards ask two questions about quality and safety: • How good is our care? • How do we compare to others providing the same service? • Is our care getting better? • Are we on track to achieve our key quality and safety objectives? • If not, why not? Is the strategy wrong, or is it not being executed effectively?

48. Recommendations for Board use of“How do we compare to others?” • Ask this question to help you set aims, and perhaps annually thereafter, but don’t use these sorts of reports to oversee and guide improvement at each meeting. • Compare to the best, not the 50th %tile • e.g., Toyota Specifications • Always make sure you know how “Green” is determined

49. Summary of Best Practices for Dashboards • Ask the ‘improvement question’ at every meeting, and track with a dashboard that shows real-time data on system level and driver measures displayed on run charts • Ask management and medical staff to share their strategy to achieve the annual quality and safety aims

50. Where do we go from here? • Where is your hospital on the five governance attributes? • Ensure process and outcome goals and measures are regularly evaluated by leadership. • Commit to transparency and reliability … expect 10-2 performance. • Develop quality and performance capacity on the board & medical staff. • Create a strategic plan for quality and performance improvement .. incorporate the 5M Lives Campaign. • Participate fully in regional and state-wide quality projects and collaboratives.