Leading Transformational Change

Leading Transformational Change:

The Big Picture

South Carolina Hospital Association

2010 Patient Safety Symposium

Columbia, SC

Maureen Bisognano

Executive Vice President and COO

Institute for Healthcare Improvement

Objectives

After this session, participants will be able

to:

─ Identify key drivers for leaders seeking to

thrive in a new environment

─Define a portfolio of new designs that will

improve patient health and experience and

drive down costs

Health Care Expenditure Out of GDP

Difficulty Getting Care on Nights, Weekends, Holidays Without

Going to the Emergency Room, Among Sicker Adults

International Comparison

Percent of adults who sought care reporting ―very‖ or ―somewhat‖ difficult

2005 2007

United States

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

7681

88 8489 89

99 9788

97

109 106

116 115 113

130134

128

115

65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

0

50

100

150

Fra

nce

Japan

Aus

tral

ia

Spa

in

Ital

yC

anad

aN

orw

ayN

ether

lands

Sw

eden

Gre

ece

Aus

tria

Ger

man

yFin

land

New

Zea

land

Den

mar

k

Uni

ted K

ingdo

m

Irel

and

Por

tugal

Uni

ted S

tate

s

1997/98 2002/03

Deaths per 100,000 population*

* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial

infections.

See report Appendix B for list of all conditions considered amenable to health care in the analysis.

Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization

mortality files (Nolte and McKee 2008).

Mortality Amenable to Health Care

HEALTHY LIVES

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 5

http://www.commonwealthfund.org/Maps-and-Data/State-Scorecard-2009/DataByState/State.aspx?state=SC










South Carolina HSMRs

50

60

70

80

90

100

110

120

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Reg

ressio

n A

dju

ste

d H

SM

R

Year

Regression-Adjusted Hospital Standardized Mortality Ratios (HSMRs) for South Carolina Hospital Referral Regions (HRRs)

Charleston HRR

Columbia HRR

Florence HRR

Greenville HRR

Spartanburg HRR

USA Medicare

So What If . . .

• Together, in this room, we set out to be as

safe as Ascension, or safer?

• Together, we design care across the

boundaries of our buildings?

• Together, we engage all to make our

families, friends, and staff healthier?

• Together, we show Washington that better

care can cost less?

So What If . . .

• Together, in this room, we set out to

be as safe as Ascension, or safer?

• Together, we design care across the boundaries of our buildings?

• Together, we engage all to make our families, friends, and staff

healthier?

• Together, we show Washington that better care can cost less?

Ascension Health’s Strategy

• Health care that works

• Health care that is safe

• Health care that leaves no one behind

─No preventable deaths by July 2008 across

the entire Ascension system

─No preventable harm by July 2008 across the

entire system

Pressure ulcers

Falls with harm

Medical errors

Birth trauma

Mortality Reduction Driver Diagram

Reduce

mortality

by 12%

this year

Primary Drivers

Leadership

Communication

between caregivers

High risk patient care

Intensive/Critical care

Prevention

Secondary Drivers

Analysis of mortality causes

2x2 review of last 50 patient deaths

Global Trigger Tool review of patient deaths in boxes 3

and 4

Board review on mortality

Standardization of patient handoffs

SBAR training for clinical staff & physicians

Multi-disciplinary rounds

Identification of attending physician for all patients

Implement birth bundles

Identification of high risk patients on admission and

during assessments

Rapid Response Team

Increased nursing and physician care

Hospitalists

Multi-disciplinary rounds

Daily goal sheets

Ventilator bundle

Glycemic control

Remote monitoring of patients

Intensivists

Influenza vaccine status of pneumonia patients

Community partnerships to promote care that prevents

critical illness

Eliminate falls with harm

Eliminate pressure ulcers

Perinatal Safety (Birth Trauma)Seton Medical Center – Austin, TX

St. Mary’s Medical Center – Evansville, IN

S t. M a ry 's B ir th T ra u m a s - C Y 2 0 0 5

10 .3 0 %9 .15 % 8 .6 3 %

13 .9 5 %

17 .3 6 %

16 .0 0 %

12 .0 6 % 12 .5 0 %

18 .8 7 %

12 .6 9 %

7 .2 6 %

10 .5 8 %

1.8 2 % 1.3 9 %

2 .9 9 %

1.6 1% 1.9 2 %

0 % 0 % 0 % 0 % 0 % 0 % 0 % 0 % 0 % 0 % 0 %0 .0 0 % 0 .7 1% 1.3 2 %

1.2 6 %

0 .7 2 %0 .6 1% 0 .0 0 %

0 %

- 5 %

0 %

5 %

1 0 %

1 5 %

2 0 %

Ja n Fe b M a r A p r M a y Ju n Ju l A u g S e p O c t N o v D e c

2 0 0 5

Pe

rc

en

t D

eliv

erie

s

In s t ru m e n t -A s s is t e d D e l ive rie s S h o u ld e r D y s to c ia B irt h T ra u m a

Alpha Spread Ascension Health System

Birth Trauma Rate

2.52

2.68

1.97

3.03

1.84

2.97

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06Month

Bir

th T

rau

ma

Rate

per

100

0 L

ive

Bir

ths

Birth Trauma Rate per 1000 Live Births Linear (Birth Trauma Rate per 1000 Live Births)

Unfavorable

Favorable

National Birth Trauma Rate = 6.59 /1000

Births

IHI Target Birth Trauma Rate = 3 /1000 Births

Birth Trauma Rate Goal for

Ascesnion Health = 0 /1000 Births

N = Number of Reporting Hospitals

N = 32

N = 36

N = 36

N = 35

N = 33

N = 35

Zero!

Reducing Harm in the ICU

Ventilator Acquired Pneumonia St. Vincent’s Hospital, Birmingham


ICU/CVICU Combined VAP Rate

0

2

4

6

8

10

12

14

16

5/1

/200

4

7/1

/2004

9/1

/2004

11/1

/20

04

1/1

/20

05

3/1

/2005

5/1

/2005

7/1

/200

5

9/1

/2005

11/1

/2005

1/1

/2006

3/1

/20

06

5/1

/2006

7/1

/2006

VA

P r

ate

Per 1

00 V

en

t d

ays

NNIS Average = 4.15 VAP per 1000 Ventilator Days

System Trend VAP Rate

3.03

3.55

2.50

2.25

1.68

2.53

2.63

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06Month

VA

P r

ate

Per 1

00 V

en

t d

ays

Vap Rate per 1000 ICU Vent days Linear (Vap Rate per 1000 ICU Vent days)

NNIS Average = 4.15 VAP per 1000 Ventilator Days

Unfavorable

Favorable

Ascension Health Goal is 0 VAP per 1000 Ventilator Days


N =43

N = 43

N = 43

N = 43

N = 44

N = 42

N =39

Zero!


Blood Stream Infections St. John’s Hospital, Detroit


BSI Rate

0

1

2

3

4

5

6

7

8

9

10

De

c-0

3

Jan-0

4

Feb-0

4

Mar-

04

Apr-

04

May-0

4

Jun-0

4

Jul-04

Aug-0

4

Sep-0

4

Oct-

04

No

v-0

4

De

c-0

4

Jan-0

5

Feb-0

5

Mar-

05

Apr-

05

May-0

5

Jun-0

5

Jul-05

Aug-0

5

Sep-0

5

Oct-

05

No

v-0

5

De

c-0

5

Jan-0

6

Feb-0

6

Mar-

06

Apr-

06

May-0

6

Jun-0

6

Jul-06

BS

I p

er 1

000 C

en

tral

Lin

e d

ays

NNIS Average = 4.22 BSI per 1000 Central Line Days

System Trend BSI Rate

1.37

1.38

1.69

2.33

1.35

1.74

1.38

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06

Month

BS

I R

ate

Per 1

000 C

en

tral

Lin

e d

ays

BSI Rate Per 1000 CL Days Linear (BSI Rate Per 1000 CL Days)

Unfavorable

Favorable

NNIS Average = 4.22 BSI per 1000 Central Line Days

Ascension Health Goal is 0 BSI per 1000 Central Line Days

N =38

N =39

N = 38

N = 39

N = 39


N =38

N =35

Zero!

Surgical ComplicationsColumbia St. Mary’s – Milwaukee, WI

Sacred Heart Hospital – Pensacola, FL

Columbia St. Mary’s - Milwaukee Sacred Heart HospitalPerioperative Adverse Event (POAE) Rate

Columbia St. Mary's, Milwaukee WI

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Mar

-04

Apr

-04

May

-04

Jun-

04

Jul-0

4

Aug

-04

Sep

-04

Oct-0

4

Nov-

04

Dec-

04

Jan-

05

Feb-0

5

Mar

-05

Apr

-05

May

-05

Jun-

05

Jul-0

5

Aug

-05

Sep

-05

Oct-0

5

Nov-

05

Dec-

05

Jan-

06

Feb-0

6

Mar

-06

Apr

-06

May

-06

PO

AE

Rate

per

Pati

en

t

POAE Rate CL UCL LCL

Perioperative Adverse Event (POAE) Rate

Sacred Heart Hospital, Pensacola FL

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

Jan-0

4

Feb-0

4

Mar-

04

Apr-

04

May-0

4

Jun-0

4

Jul-04

Aug-0

4

Sep-0

4

Oct-

04

Nov-0

4

Dec-0

4

Jan-0

5

Feb-0

5

Mar-

05

Apr-

05

May-0

5

Jun-0

5

Jul-05

Aug-0

5

Sep-0

5

Oct-

05

Nov-0

5

Dec-0

5

Jan-0

6

Feb-0

6

Mar-

06

Apr-

06

May-0

6

Jun-0

6

Jul-06

PO

AE

Rate

per

Pati

en

t

POAE Rate CL UCL LCL

Zero!

Pressure Ulcer Prevention

Facility Acquired Pressure Ulcer RateSt. 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

1.171.17

1.001.03

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

10/1

0/0

5

WE

10/2

4/0

5

WE

11/7

/05

WE

11/2

1/0

5

WE

12/5

/05

WE

12/1

9/0

5

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


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 6

M o n t h

Pre

su

re

U

lc

er R

ate

p

er 1

00

0 P

atie

nt D

ay

s

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

National Rate:

Zero!


Borgess Medical Center

Non-Critical Care Codes per 1,000 discharges

0

2

4

6

8

10

Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06

NON-CC CODES (per 1000 disch)

Non-Critical Care Code Rate by Month for Reporting Hospitals

3.19

3.07

3.293.23

3.47

3.38

3.25

3.563.50

2.84

2.96

2.85

2.71

2.4

2.6

2.8

3.0

3.2

3.4

3.6

Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06

Rate p

er 1000 D

isch

arg

es

Non-Critical Care Code Rate per 1000 DischargesLinear (Non-Critical Care Code Rate per 1000 Discharges)

favorable

unfavorable

N= Number of Reporting Hospitals

Non-CC Code Rate Goal for

Ascension Health: 0 / 1000

Discharges

n=25 n=27 n=24 n=24 n=22 n=22 n=36 n=34 n=35 n=35 n=35 n=37 n=33

33 hospitals reporting: Overall Rate 2.71


Rapid Response Teams – Non-Critical Care Codes and RRT CallsBorgess Hospital, Kalamazoo

Error Reduction at Ascension

Pressure Ulcer

Neonatal mortality

Birth Trauma

Ventilator-acquired pneumonia

Falls with serious injury

Blood-stream infections

Preventable Error Reduction in rate

95%

79%

74%

56%

54%

32%

July, 2008 Update: ―A Partial Success‖

• Ascension set a goal of preventing 900

unnecessary deaths by Summer 2008.

• In July, they announced they had, in their

estimation, prevented 2,700 deaths –

three times their stated goal.

Ascension Health: New Aim

Healing Without Harm

by 2014

Palmetto Hospital Mortality Rates

So What If . . .

• Together, in this room, we set out to be as safe as Ascension, or

safer?

• Together, we design care across the

boundaries of our buildings?


healthier?


A Case Study From University of

Pittsburgh Medical Center (UPMC)

• Aims in redesigning care for patients

undergoing total joint replacement1. Patient and family education

2. Less invasive techniques

3. Multimodal anesthesia and pain management techniques

4. Rapid rehabilitation protocols

5. Rapid outcomes feedback (from the patients’ and the

providers’ perspectives

6. Creating a learning environment and culture

7. Developing a sense of community, competition and teamwork

among patients and between patients, caregivers and staff

8. Promoting a wellness (rather than sickness) approach to

recovery DiGioia A, Greenhouse P, Levison T. ―Patient and Family-

centered Collaborative Care: An Orthopaedic Model‖.

Clinical Orthopaedics and Related Research. 2007: 463;

pp: 13-19.

Tony DiGioia

Dr. Anthony M. DiGioia III, orthopedic surgeon

and developer of the patient- and family-centered

care program for UPMC, in his office at Magee-

Womens Hospital in Oakland.

A Case Study From UPMC

• New Designs:

─Pre-op testing, teaching

─Coaching meetings with other patients

─Pre-surgery discharge planning

─Strong focus on complete pain management

─―Wellness‖ design in orthopedics unit

DiGioia A, Greenhouse P, Levison T. “Patient and Family-

centered Collaborative Care: An Orthopaedic Model”. Clinical

Orthopaedics and Related Research. 2007: 463; pp: 13-19.

Results

• Safe:

─Mortality rate: 0%

─ Infection rates: 0.3% (0.2% for TKA and 0.7%

for THA)

─Zero dislocations

─SCIP compliance: 98% for antibiotics within one

hour of surgery




Results

• Effective:

─95% of patients discharged without handheld

assistance directly to home (national rates:

23-29%)

─99% of patients reported that pain was not an

impediment to physical therapy, including

same-day-of-surgery physical therapy




Results

• Patient-centered:

─ Press-Ganey mean satisfaction score is 91.4% (99th

national percentile ranking) with 99.7% positive

responses to ―Would you refer family and/or friends?‖

• Efficient:

─ Average length of stay:

2.8 days for TKA (national average is 3.9 days)

2.7 days for THA (national average is 5.0 days)

─ One MD able to perform 8 joint replacements before

2:00pm




Other PFCC Projects at UPMC

• Day of Surgery (UPMC Presbyterian)

• Human Resources – The New Hire Experience (UPMC

Corporate)

• Trauma (UPMC Presbyterian)

• Wayfinding / Lobby (Magee-Women’s Hospital)

• Rheumatology (Children’s Hospital of Pittsburgh)

• Minimally Invasive Bariatric and General Surgery

(Magee-Women’s Hospital)

• Home Health Rehabilitation (Jefferson Regional)

So What If . . .


safer?


• Together, we engage all to make our

families, friends, and staff healthier?


Health Outcomes

• 1 in 10 adults in SC has diabetes

• 22% of adults in SC smoke (compared with 18.3% nationally)

• 65.8% of adults in SC are either obese or overweight (compared

with 63% nationally)

• 15.1% of adults in SC report having a disability (compared with

12.8% nationally)

• Mortality rates amenable to health care are 115.5 per 100,000

compared with 89.9 per 100,000 nationally.

• Commonwealth Fund ranks SC 33th in US for Prevention and

Treatment in 2009 (in 2007 was ranked 35th)

What if we started with all health care workers in

out hospitals like Bellin, and then spread to our

families and friends?

Health Navigation: Bellin Health

The new gateway to

Bellin Health.

Personal, tailored

treatment to

individuals’ needs,

learning styles and

lifestyles.

Bellin Health

Cost of Employee Plan vs. AveragesBellin Health

Solutions

Program

Introduced Funded Personal

Benefit Accounts began

($500/$1000)

So What If . . .


safer?



healthier?

• Together, we show Washington that

better care can cost less?

What If . . .

We took on Tom Nolan’s

challenge to limit spending

growth to 3% per year?

The Triple Aim

Population

Health

Experience

of Care

Per Capita

Cost

The Triple Aim

• Improve Individual Experience

• Improve Population Health

• Control Inflation of Per Capita Costs

The root of the problem in health care is that the business models of almost all US health care organizations depend on keeping these three aims separate. Society on the other hand

needs these three aims optimized (given appropriate weightings on the components) simultaneously.

--- (Tom Nolan, PhD)

HealthPartners

1.0005

0.90889%

37%

0.906

0.926

0.946

0.966

0.986

1.006

4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q08 2Q08 3Q08 4Q08 1Q09 2Q09 3Q09

To

tal C

ost In

de

x

9%

17%

25%

33%

98%97%

85%

90%

95%

100%

% patients with Optimal

Diabetes Control* * controlled blood sugar (perICSI guideline A1C changed

from < 7 to < 8 in 1st quarter 2009), BP & cholesterol, AND

daily aspirin use, AND non-tobacco user

% patients “Would

Recommend” HealthPartners

Clinics

Total Cost Index

(compared to statewide average)

< 1 is better than network average

TRIPLE AIM: Health-Experience-AffordabilityHealthPartners Clinics

Domestic Triple Aim Sites

• Hospital-Based Systems

Cape Fear Valley (NC)

Bellin Health (WI)*

Cincinnati Children’s Hospital Medical Center (OH)*

Genesys Health (MI) (Ascension)*

ThedaCare (WI)

• Integrated Health Systems

Group Health (WA)*

HealthPartners (MN)*

Kaiser Permanente, Colorado Region (CO)

Kaiser Permanente, Mid-Atlantic Region (MD)

Martin’s Point Health Care (ME)

Presbyterian Healthcare (NM)

Southcentral Foundation and Alaska Native Medical

Center (AK)

Veterans Health System:

VISN 10—Cincinnati VAMC (OH)

VISN 20—Portland VAMC (OR)

VISN 23—Nebraska, Western Iowa VAMC (NE)

• Health Plans

Blue Cross Blue Shield of Michigan (MI)

CareOregon (OR)*

Eastern Carolina Community Plan (NC)

New York-Presbyterian System SelectHealth, LLC

(NY)*

UPMC Health Plan (PA)

Independent Health (NY)

Wellmark (IA)

• Public Health Department

King County Department of Public Health (WA)

• State Initiative

Vermont Blueprint for Health (VT)*

• Safety Net

Colorado Access (CO)

Contra Costa Health Services (CA)*

North Colorado Health Alliance (CO)*

Primary Care Coalition Montgomery County (MD)*

Queens Health Network (NY)*

• Employers/Businesses

QuadGraphics/QuadMed (WI)*

• Social Services

Common Ground (NY)* Sites that participated in the first phase of Triple Aim Prototyping.

International Triple Aim

Prototyping Sites

• Jonkoping (Sweden)

• NHS Blackburn With Darwen PCT (NW England)

• NHS Bolton PCT (NW England)

• NHS Bournemouth and Poole (SW England)

• NHS East Lancashire Teaching PCT (NW England)

• NHS Eastern and Coastal Kent PCT (South East Coast England)

• NHS Forth Valley (Scotland)

• NHS Heywood, Middleton and Rochdale PCT (NW England)

• NHS North Lancashire Teaching PCT (NW England)

• NHS Medway (South East Coast England)

• NHS Oldham PCT (NW England)

• NHS Salford PCT (NW England)

• NHS Somerset PCT (SW England)

• NHS Swindon PCT (SW England)

• NHS Tayside (Scotland)

• NHS Torbay Care Trust (SW England)

• NHS Blackpool PCT (NW England)

• NHS Bury PCT (NW England)

• NHS Central Lancashire PCT (NW England)

• NHS Sefton PCT (NW England)

• NHS Warrington PCT (NW England)

• NHS Western Cheshire PCT (NW England)

• NHS Wirral PCT (NW England)

• State of South Australia, Ministry of Health (Australia)

• Western Health and Social Care Trust (Northern Ireland)

Last Updated 7/21/09

Thriving Under Reform

Improve Safety

Engage Patients

Improve Efficiency

Leadership

Reduce medical errors and harm

Reduce “never events”

Chronic conditions self-management

Prevention and wellness (start with your staff)

Transparency for high-performing providers

Shared decision making

New models for medically complex patients

Palliative care improvement

Reduce artificial variation (LOS, use rates, readmissions, etc.)

Eliminate “flow faults”

Set a goal of reducing waste by 1-3% of operating expense budget for I year, year on year

Create a culture of getting value for money

Adopt a proactive approach to errors and harm to reduce malpractice claims and costs

Engage the Board

Leadership Driver Diagram for Thriving Under Reform

Thank You!

• Maureen Bisognano

Executive Vice President and COO

Institute for Healthcare Improvement

20 University Road, 7th Floor

Cambridge, MA

[email protected]

617-301-4800

mailto:[email protected]

Documents

Leading Transformational Change