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IOM's Quality Through Collaboration: Ya Sure, Minnesota Can Do That!
Clint MacKinney, MD, [email protected]
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
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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
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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
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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
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The Healthcare Landscape
–We do whacky things–Questionable healthcare value –Pay for performance–Provider accountability
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Glitches Happen
Oops. Uh, sorry about scratching your truck.
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Every system is perfectly designed…
Look! It only takes one guy and one ladder to change a light bulb!
(Timber!)
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…to achieve the results that it yields.
Ouch!
(or maybe)
D’ Oh!!
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Healthcare Safety Strategy?
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The Healthcare Landscape
–We do whacky things–Questionable healthcare value –Pay for performance–Provider accountability
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Healthcare Value
Value = Quality + Service
Cost
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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
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Healthcare Value (Service)
81
82
83
84
85
86
87
All OtherHospitals
RuralHospitals
CriticalAccess Hosp
Overall Mean Score Inpatient Satisfaction
Press Ganey National Database. Presented at HealthLeaders Forums. 2005.
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Healthcare Value (Cost)
30%
70%
Costs of PoorCare
AppropriateHealth CareCosts
Causes of poor care: Misuse, underuse, overuse, waste – Juran Institute and Midwest Business Group on Health. 2003
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Healthcare Value (Cost)
Harris Interactive Poll (quoted by Steve Wetzell, 2005)
0%
10%
20%
30%
40%
50%
60%
70%
Clothes Food Cars Doctors Drugs Hospitals
% Who Think Prices are Unreasonable High
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The Healthcare Landscape
–We do whacky things–Questionable healthcare value –Pay for performance–Provider accountability
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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
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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
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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
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The Healthcare Landscape
–We do whacky things–Questionable healthcare value –Pay for performance–Provider accountability
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Accountability Agents
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New Paradigm
“No margin – no mission”
to
“No outcome – no income”
– Charles Denham National Patient Safety
Foundation
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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?
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Cornerstones of Success
Safety and Patient Quality Experience
Community Health
Financial Employee Stability Growth
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Culture
What does “culture” mean to you?
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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
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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
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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
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Defining Mission
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Cultural Determinants
•Walking the Mission talk?
•The congruence of:Mission – Operations – Budget – 3
Rs
•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?
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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)
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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
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Leadership
What does “leadership” mean to you?
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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.
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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
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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
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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
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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
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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
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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.”
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Safety and Quality
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Safety and Quality
• Safety and Quality?• Organizational Culture?• Both!
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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
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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)
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
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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
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
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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
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
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Communication
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Communication – The First and Last Defense
INJURY
GLITCH
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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.
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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
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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
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Changes
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Goal: Healthy Communities