The Basics and the Myths:

“Because I need to…”

Donald M. Berwick, MD IHI/BMJ International Forum

on Quality & Safety in Health Care London, England: April 24, 2015

Nathaniel Learns and Improves 2

Caleb and the Balloon 3

Erector Set 4

Coffee in the Loo

Coffee in the Loo

“They tell us not to do it…”

The World Converges: Concerns in Common

Aging and Chronic Disease

Health Care Costs

Percent Change in Massachusetts State Budget

Expenditures FY2001-FY2015

The World Converges: Concerns in Common

Aging and Chronic Disease

Health Care Costs

How to Create Health

Safety

Person-Centered Care

Transparency

Technology

Nations in Motion

English NHS: “Five Year Forward View”

Scotland: “Early Years Collaborative”

Portugal: “Health in Portugal: A Challenge for the

Future”

Denmark: “Citizens’ Health Care System”

Singapore: Agency for Integrated Care

China: 5-Year Plan for the Health Sector 2016-

2020

Population

Health

Experience

of Care

Per Capita

Cost

The Triple Aim

NHS England’s Five Year Forward View

Radical Upgrade in Prevention and Public Health

Great Patient Control over Their Own Care

Better Joining-Up… – GP’s and Hospitals

– Physical and Mental Health

– Health and Social Care

Local Innovation – “Radical New Care Delivery Options” – Multispecialty Community Provider (MCP)

– Primary and Acute Care Systems (PACS)

– A&E, Smaller Hospitals, Midwifery, etc.

Strengthen List-Based Primary Care

Coherent National Leadership

Close the £30B Gap – Demand (Prevention, Out-of-Hospital Care, Carer Support, etc.)

– Efficiency (>2% per year)

– Funding

Population

Health

Experience

of Care

Per Capita

Cost

Five Year View and Triple Aim

• Chronic Disease

Coordination

• Sepsis

• Kidney Damage

• Mental Health Care

• A&E

• “Radical Upgrade in

Prevention and

Public Health”

• Diabetes Prevention

• NHS Staff Well-

Being

• Demand

• Efficiency

• Revenue

Choluteca River Bridge 1938…

15

Hurricane Mitch - 1995

But, the River Moved…

Model I: Bad Apples

The

Problem

Quality

Frequency

Model I: Bad Apples

The

Problem

Quality

Frequency

“Reliance on Inspection to Improve”

The Cycle of Fear

Increase

Fear

Micromanage Kill the

Messenger

Filter the

Information

Dr. Joseph M. Juran’s “Trilogy” 20

QUALITY

PLANNING

QUALITY

IMPROVEMENT

QUALITY

CONTROL

Three Populations: “The Trilogy”

Quality

Frequency

Control Invention

Improvement

Model 2: Continuous Improvement

“Every Defect is a Treasure”

Quality

F

req

uen

cy

NEJM : 364: 23, June 9-2011, Arora S, Thornton K, Murata G

ECHO Treatment Outcomes:

Equal to University Medical Center

Hepatitis C Outcome ECHO UNMH P-value

N=261 N=146

Minority 68% 49% P<0.01

SVR (Cure) Genotype 1 50% 46% NS

SVR (Cure) Genotype 2/3 70% 71% NS

SVR=sustained viral response

Arora S, Thornton K, Murata G. NEJM 2011; 364:23

Adult Visual Acuity

Paediatric Visual Acuity

Color Vision

Contrast Sensitivity

Visual Fields

Pupil Assessment

Lens/Cataract Examination

Retinal Examination

Software tests

Hardware adapters

Platforms

Systems

Active in trials in:

• Kenya

• Tanzania

• India

• Mali

• Malawi

• Botswana

• UK

PEEK: Telemedicine at Scale

PEEK: Telemedicine at Scale

PEEK: 10,000

Children Screened

per Week by

Teachers in Kenya

Programs that Patients Love. CareMessage creates highly engaging mobile programs to improve health literacy and

disease self-management skills for diverse populations.

Photo: Tomasa, a mother of two, is participating in a CareMessage program to take control of her

health.

CareMessage

BACKGROUND / WHY SMS?

SOURCES

Smith, A., “Americans and Text Messaging” Pew Research Center. Sept 2011

USAGE BY EDUCATION LEVEL USAGE BY INCOME LEVEL

0

15

30

45

60

75

<$30K $30K–50K $50K-75K $75K+

Me

an

# o

f S

MS

Se

nt/

Re

ce

ive

d

pe

r

Da

y

Income Level

0

17.5

35

52.5

70

87.5

Less than HS HS Diploma Some College College+

Mean

# o

f S

MS

Sen

t/R

eceiv

ed

p

er

Day

Education Level

SMS usage is more prevalent in lower income

and less educated populations.

CareMessage

Discover a Sample Program.

SugarTalk and PlaticaDulce are

year long programs that comprise

shorter 4-6 week long modules

addressing topics most relevant to

type 2 diabetics - such as properly

injecting insulin, recognizing a high

or low blood glucose or avoiding

culturally-specific foods that tend to

increase blood glucose. The

programs are tailored to various

factors, including disease

progression, age, gender, ethnicity

and cultural preferences.

PláticaDulce

CareMessage

Ghana “Fives Alive” - Start Small, Scale

Up Rapidly with Change Package

Start-up:

Months 1-8

Total Population:

Under 5 Population:

Nov 2007

Wave 1:

Months 9-22

350,000

60,000

Jul 2008

Wave 2:

Months 23-63

5 million

500,000

Sept 2009

Wave 1R:

Months 58-89

11 million

1.7 million

Aug 2012

No of. QI Teams: 30 258 350 369 >1,046

Jan 2013

Wave 3:

Months 24-89

11 million

1.7 million

Oct 2009

Wave 4:

Months 63-89

22 million

3.3 million

*Referral project launch

41 Referral Teams

Sub-District Quality Improvement

Team: Ghana “Project Fives Alive”

Overall U5MR – 132 Ghana Hospitals

27.8% Decline

An Example of a Simple Rule for Redesign

“Make It a Game.”

“Make It a Game”:

Waze Traffic and Navigation App

“Make It a Game”:

Waze Traffic and Navigation App

I am a Warrior Wazer!!!!

(Whatever that is…)

“Make It a Game”:

Trip Advisor Passport Badge

“Make It a Game” 39

“Make It a Game” 40

“Make It a Game” 41

“Make It a Game” 42

Radical Redesign Principles - IHI Leadership Alliance

Change the Balance of Power

Standardize What Makes Sense

Customize to the Individual

Collaborate/Cooperate

Eliminate Walls

Assume Abundance/Return the Money

Make It Easy

Move Knowledge, Not People

Create Wellbeing

Create Joy in Work

Organizational Elements

for Continual Improvement

Strategy

Culture Technique

45

What are we trying to Accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

The Model for Improvement

Act Plan

Study Do

When you

combine

the 3

questions

with the…

…the Model

for

Improvement. PDSA cycle,

you get… A Model

for Learning and Change Source: The Improvement Guide p. 10

Organizational Elements

for Continual Improvement

Strategy

Culture Technique

Myths to Abandon

1. Incentives Will Save Us

2. “Skin in the Game” Will Save Us

3. Measurement Will Save Us

4. Accountability Will Save Us

5. Standards Will Save Us

6. Markets Will Save Us

7. Technology Will Save Us

8. Health Care Will Save Us

What Leaders Can Do….

Declare the need to improve… set bold aims

Establish transparent, system-level metrics

Give voice to patients, carers, communities

Invest in workforce skills to improve

Cease fear and blame… Develop pride and joy in

work

Learn together… a “Learning World”

49

Nathaniel and Caleb: Joy in Work 50