Collaborative Improvement: A Brief and Recent History

Healthcare Learning Collaboratives: Lessons Learned and Future Opportunities

Baltimore, MD: November 4 , 2015

November 4, 2015

Donald M. Berwick, MDPresident Emeritus and Senior FellowInstitute for Healthcare Improvement

Model I: Bad Apples

The ProblemQuality

Frequency

Model I: Bad Apples

The Problem

Quality

Frequency

“Reliance on Inspection to Improve”

The Cycle of Fear

Increase Fear

Micromanage Kill theMessenger

Filter theInformation

Some Consequences of Reliance on Inspection

Measurement Gone Wild – Adds massive costs; Distracts from what matters; Objectifies the crucial subjectiveAccountability – Chills dialogue and authentic exchange; Loses upward information flow“Skin in the Game” – Afflicts the disadvantaged; Lacks any evidence baseStandardization – Chills innovation; Disconnects care from individual patientsMarkets – Drives oversupply; Chills exchange 5

“The First Law of Improvement”

Every system is perfectly designed to achieve exactly the

results it gets.Paul Batalden, MD

“Some heades haue taken two head is better then one: But ten heads without wit, I wene as good none.”

- John Heywood, 1546 AD

Paul Batalden, MD

9

“IHI creates membership Organization”

“IHI creates the interpretation of this around conditions”

“IHI organizesactivities”… “produces

stories”

“Pain…Flow…Drugs”

10

Breakthrough Series Collaborative

Pick a topic for improvement

Engage a panel of experts

Harvest “change concepts”

Invite care organizations to enroll teams

Launch a series of learning sessions

Use the learning sessions to teach improvement

Summarize

1. Ideas2. Cycle Times

3. Social Support – Affirmation

“50/50”

“If I don’t discover it,I don’t value it”

“4. Problem level, notmacrounit level. Hospital

as a system”

“The real team is atthe hospital”

“Could do costreduction”

“Reflection asa process”

“Up front: Ask wherein the system there

is a need forimprovement”

“Observe atsystem level”

“Tom Nolan’sphone number”

“Memo to theBoard”

Tom Nolan, PhD

Criteria for Selection16

Clinical importance to patients

Financial importance to organizations

Experts have achieved better performance

Choose cycle times and scale that permitted noticeable improvement within weeks or months

Seek out best practice sites and great ideas for change.

52 Breakthrough Series Collaboratives

Dr. Ken Kizer, Veterans Health Administration19

Vertically Integrated Service Networks (VISNs)20

22 VISNs; total of 134 VA centers

8-Month Results:

Median wait times fell from 48 to 22 days

54% reduction in wait time

3-Year Results:

Wait times fell from >60.4 days to 28.4 days

VISN 2 achieved wait times of 16 days

Dr. John Oldham22

National Primary Care Development

Team (PCDT)

Development Team (NPDT) focus:– Access to primary care– Care for patients with proven coronary heart disease– Access to routine secondary care services.

11 regional PCDT organizations

1000 practices in the UK covered 7 million patients

Reduced waiting times for >32 million patients

The largest improvement program in the world, 2002

Reduction in GP 3rd available appointment - July to September 2000For practices reporting full data and showing improvement in measure over the period

(Represents 45% of practices reporting full data for the period)

0

2

4

6

8

10

12

All practices showing improvement in GP 3rd available appointment measure during the period

Red

ucti

on

in

days t

o 3

rd a

vail

ab

le a

pp

oin

tmen

t -

GP

s

% no of practices achieving GP 3rd Available Appointment within 48hrsThird wave practices

30.0

35.0

40.0

45.0

50.0

55.0

60.0

65.0

70.0

Pe

rce

nta

ge

% no of practices

Wave 3 Collaborative practices Average No. of days - GP 3rd Available Appointment

% Improvement from baseline (April 2000) to September 2001

0

1

2

3

4

No

. o

f d

ays

0

10

20

30

40

50

60

70

80

90

100

%

Average of GP_3rd_Appointment 3.47 3.28 3.06 2.84 2.62 2.23

%Improvement from baseline 0.00 5.48 11.82 18.16 24.49 35.85

Apr-01 May-01 Jun-01 Jul-01 Aug-01 Sep-01

NB : baseline April 01 - 3.47 days

The National Primary Care CollaborativeGP 3rd Available Appointment Trends

First, Second and Third Wave practices

1.5

2

2.5

3

3.5

4

4.5

Avera

ge 3

rd a

vail

ab

le a

pp

oin

tmen

t (d

ays)

First w ave practices 3.3 3.2 2.8 2.9 2.7 2.7 2.3 2.1 2.0 2.1 2.4 2.4 1.8 1.6

Second w ave practices 4.1 3.9 3.7 3.0 3.1 3.1 3.2 3.2 2.6 2.3 1.9

Third w ave practices 3.6 3.5 3.3 3.1 2.8 2.6 2.2

Baseline Month 1 Month 2 Month3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Month 13 Month 14

GP Access % Improvement Wave 1 - 50.38% over 14 months of reportingWave 2 - 52.23% over 10 months of reporting Wave 3 - 35.85% over 6 months of reporting

Learning over Time:“Plan-Do-Study-Act” Cycles

in a Large System

Wave 1Wave 3

Wave 2

Early Care Improvement Collaboratives

Pressure Ulcer PreventionFacility Acquired Pressure Ulcer Rate

St. Vincent Hospital, Jacksonville

Overall PU ratio by week

0.38

1.93

2.53

2.11

2.46

0.390.37

0.75

1.90

1.04

3.31

0.36

0.74

1.171.171.001.03

2.78

1.47

1.03

0.32

1.01

0.32

0.69

1.68

0.32

0.94

1.65

2.00

1.05

0.69

0.340.33

0.990.99

1.38

0.71

1.05

0.71

1.411.39

0.39

0.00

0.35 0.39

0.75

1.07

0.69

0.37

1.46

0.35

0.67

1.07

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

WE

8/2

9/0

5

WE

9/1

2/0

5

WE

9/2

6/0

5

WE

10

/10

/05

WE

10

/24

/05

WE

11

/7/0

5

WE

11

/21

/05

WE

12

/5/0

5

WE

12

/19

/05

WE

1/2

/06

WE

1/1

6/0

6

WE

1/3

0/0

6

WE

2/1

3/0

6

WE

2/2

7/0

6

WE

3/1

3/0

6

WE

3/2

7/0

6

WE

4/1

0/0

6

WE

4/2

4/0

6

WE

5/8

/06

WE

5/2

2/0

6

WE

6/5

/06

WE

6/1

9/0

6

WE

7/3

/06

WE

7/1

7/0

6

WE

7/3

1/0

6

WE

8/1

4/0

6

WE

8/2

8/0

6

Alpha Spread Ascension Health System

1 .5 7

1 .6 61 .6 3

1 .3 8

1 .4 1

1 .2 7

1 .4 8

0 .5 0

1 .0 0

1 .5 0

2 .0 0

J a n - 0 6 F e b - 0 6 M a r - 0 6 A p r - 0 6 M a y - 0 6 J u n - 0 6 J u l- 0 6M o n t h

Pre

su

re

Ulc

er R

ate

pe

r 1

00

0 P

atie

nt

Da

ys

P r e s s u r e u lc e r r a te p e r 1 0 0 0 In p a t ie n t D a y s L in e a r ( P r e s s u r e u lc e r r a te p e r 1 0 0 0 In p a t ie n t D a y s )

U n f a v o r a b le

F a v o r a b le

N = 5 0

N = 5 0

N = 5 1

N = 5 0

N = 5 0

N = N u m b e r o f R e p o r t in g H o s p it a ls

N = 5 1

N = 5 0

50 hospitals reporting: Overall Rate 1.38

Zero!

Error Reduction at Ascension

Pressure Ulcer

Neonatal Mortality

Birth Trauma

Ventilator-Acquired Pneumonia

Falls with Serious Injury

Bloodstream Infections

Preventable Error Reduction in rate95%

79%

74%

56%

54%

32%

OPQC = Population HealthOhio Perinatal Quality Collaborative

30

39 Weeks & Birth Registry Accuracy105 (of 107) Maternity Hospitals

NAS52 (of 54) Level II and III NICUs

ProgesteronePilot: 23 OB ClinicsSpread: +15-20 OB Clinics

NICU Grads Pilot: 3 NICUsSpread: +3 NICUs

API - 2015

Decreasing Non-Medically Indicated Scheduled Deliveries Prior to 39 Weeks Gestation

31API - 2015

API - 2015 32

Q1

Q3

Q1

Q3

Q1

Q3

Q1

Q3

Q1

Q3

Q1

Q3

Q1

Q3

Q1

Q3

Q1

Q3

Q1

Q3

0102030405060708090

100Total Number of Centers (Cumula-

tive)

Cumulative Actual

Num

ber o

f Cen

ters

ImproveCareNow Network

• Industry sponsored research studies – Adalimumab Concomitant Therapy• Methotraxate Trial• PCORI PPRN Phase 1 & 2• Research objectives elicitation & prioritization (CHOP)• PRO collection – PROMIS study• PPRN demo PFA

Funded Research

Inflammatory Bowel Disease Remission Rates:“Improve Care Now” Care Centers

Patient Safety Collaboratives: Today

Modifications for Resource-Poor Settings36

Coaches

Regional meetings

Cell phone technologies

Overcome geographic, financial constraints

Photo: FreeDigitalPhotos.net

“The Breakthrough Series (BTS) structure has proven highly applicable to efforts to improve performance of the more centrally directed, district-based health systems in Africa.

Lack of Internet connectivity necessitated reliance on change agents who pollinated change ideas across sites in the network…

…[the BTS] became a learning system used primarily for innovation of changes that could then be spread.  The BTS was also used as a spread mechanism for IHI’s Ghana project on maternal and neonatal mortality…In South Africa, the BTS model was used for innovating and demonstrating effective implementation of HIV care at a District level, and developing change packages that were then spread throughout the national health care system…  

- Pierre Barker, 2015 

Paul Batalden’s Sketch38

Breakthrough Series Skeptics 39

Doubts about scientific discipline of measurement, inference, results reporting

Doubts about data

Doubts about attribution

Doubts about sustainability: Do these results last?

Lingering Questions40

“Do improvement collaboratives work?”

…“Does parenting work?”

…“Does schooling work?”

Photo: http://www.boas.pro/remco-boas

41

Pawson and Tilley: Realistic Evaluation

“The idea [of collaborative improvement] is better seen as a learning strategy – an action learning strategy – not as an intervention that should be evaluated as a new treatment should be.”

- Paul Batalden, 2015  

“The bedrock value within a collaborative is freedom from fear in any form – fear of

inspection, fear of failure, fear of reprisal.”

- Kedar Mate, 2015

“Never worry alone.”

- Institute for Healthcare Improvement