IOM's Quality Through Collaboration: Ya Sure, Minnesota Can Do That! Clint MacKinney, MD, MS...

IOM's Quality Through Collaboration: Ya Sure, Minnesota Can Do That!

Clint MacKinney, MD, MSclintmack@cloudnet.com

Duluth, MinnesotaJuly 18, 2005

22005 Minnesota Rural Health Conference

Topics for Today

1.A brief introduction to the Institute of Medicine’s Quality Through Collaboration: The Future of Rural Health

2.The healthcare landscape; why change is coming (whether we like it or not!)

3.The elusive (but oh-so-important) topic of organizational culture

4.The requisite of leadership

5.Patient safety is job one

6.Quality improvement follows on safety’s heels

Committee on the Future of Rural Health Care

•Quality Through Collaboration: The Future of Rural Health– Institute of Medicine’s Quality

Chasm Series

– Available at www.nap.edu

– Executive Summary (.pdf) is free

•Five-pronged strategy to address rural healthcare quality challenges

•Key findings and recommendations

Five-Pronged Strategy

1.Addressing personal and population health needs

2.Establishing a quality improvement support structure

3.Strengthening human resources

4.Providing adequate and targeted financial resources

5.Utilizing information and communications technology

IOM’s 30,000-Foot View

• Written from a national perspective.

• Recommendations for federal policy.

• Challenge is to “bring it down” to local levels.

• Emphasis today – How we can improve:

– Culture

– Leadership

– Safety and Quality

The Healthcare Landscape

–We do whacky things–Questionable healthcare value –Pay for performance–Provider accountability

Glitches Happen

Oops. Uh, sorry about scratching your truck.

Every system is perfectly designed…

Look! It only takes one guy and one ladder to change a light bulb!

(Timber!)

…to achieve the results that it yields.

(or maybe)

D’ Oh!!

Healthcare Safety Strategy?

Healthcare Value

Value = Quality + Service

Healthcare Value (Quality)

The Quality of Health Care Delivered to Adults in the United States – McGlynn et al

Results •Participants received 54.9% of recommended care.•45% defect rate!

Conclusions •The deficits we have identified in adherence to

recommended processes for basic care pose serious threats to the health of the American public.

NEJM. Volume 348:2635-2645. June 26, 2003. Number 26

Healthcare Value (Service)

All OtherHospitals

RuralHospitals

CriticalAccess Hosp

Overall Mean Score Inpatient Satisfaction

Press Ganey National Database. Presented at HealthLeaders Forums. 2005.

Healthcare Value (Cost)

Costs of PoorCare

AppropriateHealth CareCosts

Causes of poor care: Misuse, underuse, overuse, waste – Juran Institute and Midwest Business Group on Health. 2003

Healthcare Value (Cost)

Harris Interactive Poll (quoted by Steve Wetzell, 2005)

Clothes Food Cars Doctors Drugs Hospitals

% Who Think Prices are Unreasonable High

Pay for Performance

•Developing force for change– Approximately 100 programs– 1/3 commercial plans– Impacting both hospitals and

physicians

•Does it work?– Improved quality– Decreased utilization– Success seems to depend on

size and type of incentive

Int J Qual Health Care. 2000:12:133-42

P4P - The Social Democrats

• A rising tide lifts all boats• Broad participation is

important• Set achievable goals to

start• Reward improvement as

well as performance• Technical assistance to

help all groups succeed

Steve Wetzell. The Movement Towards Transparency and Pay for Performance. 2005.

Healthcare providers “need payment not for performance, but to support performance.”

– Don Berwick, 2005

P4P - The Darwinians

• “If you build it, they will come”

• Set the bar high• No breakthrough

without pushing• Make threshold more

difficult over time• Poor performers will

(should) get consolidated

Steve Wetzell. The Movement Towards Transparencyand Pay for Performance. 2005.

Accelerating

Accountability Agents

New Paradigm

“No margin – no mission”

“No outcome – no income”

– Charles Denham National Patient Safety

Foundation

Questions About the Future

•Should rural healthcare providers feel complacent with cost-based reimbursement, grant funding, and minimal quality reporting mandates?

•Are we in rural insulated and immune from the forces of healthcare change?

•Should our patients continue to tolerate healthcare overuse, underuse, and misuse?

•Should our patients continue to tolerate suboptimal safety, quality, and service?

Cornerstones of Success

Safety and Patient Quality Experience

Community Health

Financial Employee Stability Growth

Culture

What does “culture” mean to you?

Culture

•Culture is the invisible force behind the intangibles and observables in any organization, a social energy that moves people to act. Culture is to an organization what personality is to the individual – a hidden yet unifying theme that provides meaning, direction, and mobilization.*

•What we believe; what we do

* Kilman, Sexton, Serpa, 1985

Cultural Barriers to Safety

We have not seen substantial progress in one critical area – culture – that has the greatest potential to produce sustainable improvements in safety.

– Daniel Stryer and Carolyn ClancyBMJ. March 12, 2005

Why isn’t health care demonstrably safer? … The answer is to be found in the culture of medicine – complexity, autonomy, fear, and lack of leadership.

– Lucian Leape and Donald BerwickJAMA. May 18, 2005

The “Worstest” Cultural Barrier

Because

we’ve ALWAYS

done it

that way! Thanks to Sharon Vitousek, MDNorth Hawaii Outcomes Project

and IHI

Thanks to Sharon Vitousek, MDNorth Hawaii Outcomes Project

and IHI

Defining Mission

Cultural Determinants

•Walking the Mission talk?

•The congruence of:Mission – Operations – Budget – 3

•Questions for home:– How do day-to-day operations support the Mission?– How does the budget prioritize the Mission?– How many staff and Board meetings are devoted

to the Mission?– How are employees reinforced, recognized, and

rewarded for living the Mission?

Performance Improvement • Performance improvement is

key to an improvement culture• The Zen of performance

improvement – “In God we trust… All else show

data” (Michael Pugh)– “You can’t manage what you can’t

measure” (unknown)

– “Not all that counts can be counted and not all that is counted counts” (Albert Einstein)

– “The world is not black and white; its grayness makes life interesting and often challenging” (me)

Mission/Reality Conundrum

RWHC Eye On Health

"The math is simple, if we ignore our finances, we risk the hospital; if we ignore our quality, we risk family and friends."

Provided by Tim Size

Rural Wisconsin Health Cooperative

Provided by Tim Size

Rural Wisconsin Health Cooperative

Leadership

What does “leadership” mean to you?

IOM’s Comments on Leadership• Finding

– Rural communities engaged in health system redesign would likely benefit from leadership training programs.

• Recommendation– Skills sets such as coalition

building, community engagement, health status measurement, change agency are necessary for transformational change.

IOM. 2004. Quality Through Collaboration: The Future of Rural Health. Washington, D.C. National Academies Press.

Leaders’ Roles•Establish direction•Align people•Motivate and inspire

•Plan and budget •Organize and staff•Control and problem-

solve*

•Measure, reflect, improve, and communicate

*Kotter, 1990

Seeking “Balance” •Seek balance among

equally important (and often competing) priorities –Mission, Operations, Budget, and the 3Rs

–Quality, Patients, Employees, and Finance

•With balance, “no margin; no mission” becomes circular and meaningless

Leadership Action List Scan the external environment

and select cultural priorities Align strategy, operations, and

measures Encourage behaviors that

support a safety and quality culture

Mandate a non-punitive work environment

Build improvement capability Remember: Attention is the

currency of leadership

CEO Action List Implement patient safety

survey Select a PI champion, but

never abdicate responsibility Communicate new cultural

emphases – again and again Oversee improvement aims at

highest leadership levels Manage with data Reorganize meeting structure Drive down decision-making Engage physicians

QI Director Action List Make Quality more than a

department Categorize quality work for

optimal efficiency Develop a performance

tracking system Choose pertinent quality

measurements P – D – S – A Seek opportunities

(glitches!) for improvement Communicate and

celebrate

How Not to Start Meetings and Memos

“We need to improve morale around here – any of you boneheads have a good idea?”

“The beatings shall continue until attitudes improve.”

Safety and Quality

• Safety and Quality?• Organizational Culture?• Both!

Culture for Quality to Flourish

• Active leadership and personal involvement

• Explicit quality mission and quality targets

• Regular performance reporting and accountability

• Safe environment for reporting errors

Meyers, JA et al. Hospital Quality: Ingredients for Success – Overview and Lessons Learned. The Economic and Social Research Institute. The Commonwealth Fund. #761. July 2004

Attracting/Retaining the Right People

•Selective hiring and credentialing

•Respect and empowerment of nurses

•“Hire for attitude, train for aptitude”

•Getting the “right” people on the bus (Jim Collins)

In-House Quality Improvement Processes

• Identify where suboptimal care is delivered

•Adequately staffed QI – lead by physicians

•Deficiencies inspire discovery and correction

•Evidence-based protocols

•Team-based care management

Right Tools

• Information technology and QI staff to abstract

• Investing and developing culturally sensitive information technology

•Physicians supported to develop guideline consensus

•External training, peer networking, conferences

Communication

Communication – The First and Last Defense

INJURY

GLITCH

New Communication Strategies •Handoff / handover

– “Never leave your wingman”

•SBAR briefing strategy – Situation

– Background

– Assessment

– Recommendation

•Appropriate Assertion

•Critical language

•Huddle and Debriefing

Leonard, M., et al. Achieving Safe and Reliable Healthcare: Strategies and Solutions. Health Administration Press. Ann Arbor, Michigan. 2004.

Quality Improvement Strategies•Assess variation

•Care protocols

•Care maps

•100k Lives Campaign– Rapid Response Team

– AMI care

– Surgical site infection

– Adverse drug events

– Central line infection

– Ventilator pneumonia

In Support of the Cornerstones

• Define and engender improvement

• Lead and facilitate change

• Support and nurture the organization

• Safety and Quality• Patient Experience• Financial Stability• Employee Growth• Community Health

The cornerstones become your

vision

Changes

Goal: Healthy Communities

IOM's Quality Through Collaboration: Ya Sure, Minnesota Can Do That! Clint MacKinney, MD, MS...

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