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Institute for Healthcare Improvement
Kaiser Permanente’s Road to Transformation
IHI ForumOrlando FloridaDecember, 2009
What You Will Learn Today
Understand the six capabilities of a high performing organizationIdentify essential factors to create high functioningIdentify essential factors to create high functioning frontline teamsUnderstand the principles of employee engagement and the opportunity for continuous improvement with a unionized workforce Create a plan to establish high performing teams, an oversight process and lead 90-dayan oversight process and lead 90 day improvement portfolios with teams
Institute for Healthcare Improvement
Kaiser Permanente: the nation's largest not-for-profit health plan
Total health care delivery system
8.6 million members
Few Facts About Kaiser Permanente
headquarters in Oakland, CA
165,000 employees, 15,000 physicians
45,000 nurses, 35 hospitals, and 431 medical office buildings
Dedicated to care innovations, clinical research, health education and the support of community health
Kaiser Permanente gives almost $1 billion a year to the community through programs, grants and donations
Established 1997
31 local unions representing 96 000 frontline
Labor Management Partnership
31 local unions representing 96,000 frontline employees
Largest and most comprehensive partnership in U.S.
Shared accountability for performance improvement, learning, engagement and decision making
4
g g g g
Measurable improvements in clinical quality, member service, cost-efficiency and workplace quality
Institute for Healthcare Improvement
Membership by Region• Northern California:
3 285 068
Kaiser Permanente’s Eight Regions
3,285,068• Southern California:
3,281,915• Hawaii: 222,594• Northwest: 472,555 • Colorado: 479,980 • Georgia: 269,802 • Mid-Atlantic States:
485,401• Ohio: 137,669
(as of December 2008)
8.6 million ambulatory recordsThe world’s largest civilian deployment of an electronic health record
Integrated inpatient/outpatient record available for
KP HealthConnectTM by the Numbers*
Integrated inpatient/outpatient record available for more than 5 million members
Full clinical deployment in existing and new hospitals (total of 35) expected by early 2010
Over 3 million members actively using My Health Manager on kp.org
Almost 39 million lab test results viewed online and almost 15 million secure messages sent by members to their providers
*As of May 2009
Institute for Healthcare Improvement
PrinciplesDefining purpose Creating system view
What you will learnStrategy alignmentDrivers and portfolios
What We Will Discuss Today
LeaTo
p do
wn
Red
uce
varia
tion
Learning system
Economic and social context for changeModels of workplace
Planning and managing Building capability
Engaging the hearts and minds of the front lineCreating “line of sight” to
Bottom
uparning and im
provemen
Models of workplace learningTeam performance
Creating line of sight to strategic goalsDefining high performing unit-based teams
t
Kaiser Permanente’s Road to Transformation: Systems and Execution
Lisa Schilling, RN MPHVice President Healthcare Performance ImprovementIHI ForumDecember, 2009
Institute for Healthcare Improvement
Key Elements of Our Execution PathKey Area LeversAligning strategy Building will
Use of transparency and big dotsFocusing on quality, safety, service g q y, y,and efficiency
Execution Developing organizational capabilities
Understanding drivers of performanceOperational management of improvement
System roles in reducing variationy g
Building improvement capability Building Skills to improve by audience
Getting to scaleEvaluating effectiveness
Where we Started: Circa 1995
Quality was an assumed competencyDeveloped a strategic partnership with the Institute forDeveloped a strategic partnership with the Institute for Healthcare ImprovementParticipated in an Execution learning sessionBenchmarked organizations that were higher performers
Institute for Healthcare Improvement
Aligning Strategy
Setting the Quality Vision
“We will be recognized by our members payers and employees
We will be recognized by our members, payers, and employees as the safest, most effective and personal health care delivery system in the country.
We will be recognized by our members, payers and employees as the safest, most effective and personal health care delivery system in the country.”
Institute for Healthcare Improvement
Overall System Performance: Board Dashboard
13
TJC Index Across Hospitals: Demonstrated Progress in Reducing Variation
Range 94% - 98%
Range 85% - 95%
14
Institute for Healthcare Improvement
Discussion: Where is your organization?
Does everyone know what your strategic priorities are?How do you measure progress organizationally?y p g g yAre your priorities the same as your patients?
Execution
“Plans are only good intentions unless they i di t l d i t i t h d k”immediately denigrate into hard work”
- Peter Drucker
Institute for Healthcare Improvement
What we learned: attributes of high performing organizations
Build capability in these six areas in order to achieve breakthrough performance
Best qualityBest service
Most affordableBest place to
work
Execution focused on three critical needs
Achieve Breakthroughgoals
The ability to identify priority improvement areasImprovement part of business strategy
Spread and sustainProvide Leadership forLarge system Projects
Improvement Institute to develop skills
Existence of improvement FTEsLocal oversight groups
Systems viewmanaging portfolios
page 18
Manage Local Improvement
Develop Human Resources
Provide Day-to-DayLeaders for Micro Systems
managing portfolios
Source: Institute for Healthcare Improvement 2007
Institute for Healthcare Improvement
Managing local improvement allows a focused and resourced approach
Develop clear alignment between strategic priorities, performance goal setting, drivers and project portfolio execution to get results
page 6
Achieve Breakthroughgoals
Manage Local Improvement
Develop Human Resources
Spread and sustainProvide Leadership forLarge system Projects
Provide Day-to-DayLeaders for Micro Systems
Focus on systems view and end to end improvement based on drivers of performanceIdentify the vital few areas to focus improvement resourcesCreate clear lines of accountability and oversight
Region/Service Area/Local•Mission critical, high priority initiatives
Expert
Facility
TPL
TPL
Ops improvementresource
Region/KPPO•Manage collaborative spread•Knowledge management•Consult critical initiatives•PI training
Expert
TPL
TPL
TPL
TPL
Expert
Expert
Anatomy of a Driver Diagram
PortfolioMeasures
Portfolio accountability
Goal
Sequence
Institute for Healthcare Improvement
Building capacity to improve by developing people
Developing our people by:Using common language for the organization to lead improvementAligning executive through front line capability by matching
page 6
Achieve Breakthroughgoals
Manage Local Improvement
Develop Human Resources
Spread and sustainProvide Leadership forLarge system Projects
Provide Day-to-DayLeaders for Micro Systems
infrastructure with new skills
Experts Operational
Leaders (Executives)
ChangeAgents
(Middle M
Everyone
(Staff,
Many People Few People
Source: API 2006
(Executives)Managers, Stewards, project leads)
( ,Supervisors,
UBT lead triad)
Unit Based Teams
SharedKnowledge Continuum of PI Knowledge and Skills
Deep Knowledge
From Microsystem Theory to Operating Systems
Regional/National• Transparency• Incentives• Reduce variation• Adopt and spread all sites• Surfacing best performers
Medical Center
• Improvement priorities• Goals and drivers • Portfolios oversight, accountability• Systems view and improvement• Spread to all applicable departments
Red
uce
Varia
tion Learn and adop
Unit/Department• Multiple tests• Day to day management /improvement• 100% participation• culture
Adapted from: Batalden et al Clinical Microsystems 2005
R
pt
Institute for Healthcare Improvement
Discussion: How is your organization?
What infrastructure is in place to oversee improvement?improvement?Whose role is it to manage improvement?Whose role is it to solve problems, leadership or teams?
Building Improvement Capability
Institute for Healthcare Improvement
What Improvement Skills are Needed for Each Role?
ChangeAgents
Everyone
• Setting direction and big goals
• Execution leadershipP tf li l ti d
Experts
OperationalLeaders
(Executives)
Agents
(Middle Managers, Stewards, project leads)
(Staff, Supervisors,
UBT lead triad)
• Analysis, prioritization of portfolios
• Deep statistical process control
• Portfolio selection and management
• Managing oversight of improvement
• Being a champion and sponsor
• Understanding variation to lead
• Managing implementation and spread
• Setting goals and measures
• Identifying problems
• Mapping process• Testing change• Simple waste
reduction• Simple
standardization• Team behaviors
• Setting goals and measures• Identifying problems• Mapping process• Sequencing tests of change• Simple understanding
variation• Implementation and spread• Simple waste reduction• Simple standardization
• Deep improvement methods
• Leadership team advisory re portfolio selection, process
• Effective plans for implementation and spread
How we develop Skills in KP Leaders, IA’s and Teams
Performance Improvement
Executive Days
– Understand evidenced based strategies for performance improvement– Develop their operating strategy for the prototype process– Understand leadership sponsor and champion roles– Understand drivers of performance locally
Curricula & Learning Objectives
National T
Improvement Institute
Operational Leaders Workshop
– Gain a depth of knowledge with performance improvement methodology– Understand tools to apply and lead performance improvement projects– Understand how to determine systems and drivers of performance
– Receive exposure to PI concepts, the KP approach to PI and available resources, roles and responsibilities, PI tools
– Obtain the knowledge to drive improvement and manage information in driving decision making and the organizational culture necessary to drive world class improvement
Ch i
– Understand the KP approach to PI and leader’s role in execution– Understand the role of champions in improvement efforts
Local TrainingTraining
Champion Workshop
Front-Line StaffRIM plus
– Describe Performance Improvement timeline and process– Describe their role in the implementation of the performance improvement work– Define the difference between measurement for improvement and measurement for
accountability
– Understand the approach to address their unit’s performance improvement project.– Develop and make robust tests of change for their performance improvement project – Measure improvement using run charts– Use simple tools to standardize and simplify work areas and work flows
g
Institute for Healthcare Improvement
A Wave approach allows for testing, expansion and scale
September 2008 June 2009 2010 & 2011
Waves of Improvement Instituteop
and
Test
the
Syst
em
acili
ty le
vel
and
Impr
ovem
ent s
yste
m
faci
litie
s
pen
impr
ovem
ent
wle
dge
with
in fa
cilit
ies
• All Regions• 400 IA’s• Medical Center,
Regional, National• 15 internal faculty
Mentors• 2000+ Operations
Managers• 20,000+ Frontline RIM
Plus• PSU
• 7 regions• 200 Improvement
Advisors (Medical Center, Region, National)
• 35 UBTI’s• 15 Faculty Mentors• 1000+ Operations
managers• 10,000 Front line RIM+ staff
• 5 regions• 70 Improvement Advisors
(Medical Center)• 11 Faculty Mentors (KP)• 4 Regional mentor students• 300 operations managers• 3,500 Front line RIM+ staff
On-boarding
Dev
elo
at a
Fa
Expa
to a
ll
Dee
pkn
ow
Learning and sharing systems regionally and program-wide Improvement Institute
Implementation Expansion ContinuousImprovementComplete
We are here
Level of Project
Difficulty
• Reliable Design• Middle manager PSU• Reliable design
3,500 Front line RIM staff• Middle manager PSU• Reliable design
Organizational Capability: Knowing whether the system is sustainable
Performance Improvement Initiative Assessment Score Card
National
Leadership
0.00
1.00
2.00
3.00
4.00
5.00
LearningCulture & CommunicationBaseline pre-wave II
Current post-wave II
Targeted for sustainable performance
Systems & Process
Measurement
Capacity & Sustainment
Current Qtr Previous Qtr Target
Institute for Healthcare Improvement
Discussion: Where is your organization?
How capable are they of improving the system?Where are you in implementing an improvement systemWhere are you in implementing an improvement system, how do you plan to get to scale?How do you know when the system is capable and can continue without your support?
Example of Execution in Practice
Institute for Healthcare Improvement
Regional World Class Focus
QualityQuality
Recognized Leader in Quality
MemberEfficiency Serv
ice
MemberEfficiency Serv
ice
“10” Patient Care Experience
Leading Patient-Centered, Efficient
Care Processes
KP’s integrated model is uniquely positioned to drive improvements across quality, service and efficiency
Highly Skilled and Motivated Workforce
Drivers of EfficiencyGoals Drivers Focus Areas & Initiatives
High-risk population management
Anticipating end of life: Palliative care, advance directives
Admission alternatives
Right Venue of Care
Leading Patient-Centered,
Efficient Care Processes
Optimize Hospital
Throughput
Manage Hospital Output
Patient flow: Well-sequenced care, no delays
Evidence-based care, no needless harm
Discharge Processes
Access to and management in alternative care settings: SNF, HH, rehab, sub-acute, i ti t h
Manage Cost Structure
in-patient psych
Direct patient care expenses: HPPD, OT, Registry, attendance
Other hospital expenses: Supplies, materials, non-patient care staff, attendance
Workplace Safety: Patient and non-patient care
Institute for Healthcare Improvement
Example – Identifying and Managing Portfolios
Where? South Bay, KP-SCAL w/CMIHow? •Coordinated concurrent medication
ili i b H H l h RN
Goal: Reduce all cause 30-day Heart Failure readmissions from 15.7% to 10% by 4/1/08Goal: Reduce all cause 30-day Heart Failure readmissions from 15.7% to 10% by 4/1/08
Case Study: Readmission Reduction CHFIt takes a village to manage our heart failure patients, with the help of our local, regional and national leadership teams and the strength of our administrative infrastructure, we have been able to make an improvement with 3 key components: real time medication reconciliation at the home health visit, home health visits in a timely manner and the use of the diagnostic readmission tool. Joan Fredella, Pharm. D., Clinical Ph i t reconciliation by Home Health RN,
PharmD, and Patient in the patients home. •Improved identification of Heart Failure patients in the Hospital•Increased reliability of Home Health visit within 48 hours•Increased reliability of Out-patient Heart Failure Clinic follow up in one week•Implemented readmission diagnostic tool to identify system gaps
Pharmacist
30 Day readmission rates-HF reason
(12 month roll up)
5 0
7.0
9.0
SBAY 30 day HF readmission rates declining!Pre Work
StartedPDSA cycles
started
for H
F in
30
days
RIMPre-workstarted
•Kick Off Mtg•PDSAs Started:
1. ConcurrentMed Rev
2. Pt ID/HH ref.
Results •Reduced 30-day re-hospitalization rate to 9% (and 90 day readmission to 20%).•Improved the reliability of the Transitions Care Program component bundle measures from 61%-95%•Hard and soft $ value estimated at $1,800,000
1.0
3.0
5.0
Sept Oct Nov Dec Jan Feb Mar April
SCAL Regional SouthBay
BEST inRegion!
% p
ts. R
eadm
itted
f
TCP Pilot Started
PharmacistRole restructuredTo focus on HF
Gap AnalysisComplete
ReliableDesignWkshopPt. ID
Institute for Healthcare Improvement
Drivers of Efficiency
Leading Patient-Centered,
Efficient Care Processes
Goals Drivers Focus Areas & Initiatives
High-risk population management
Anticipating end of life: Palliative care, advance directives
Admission alternatives
Right Venue of Care
Optimize Hospital
Throughput
Manage Hospital Output
Patient flow: Well-sequenced care, no delays
Evidence-based care, no needless harm
Discharge Processes
Access to and management in alternative care settings: SNF HH rehab sub-acute EFFICIENCY
Regional focus
Prioritization and Implementation: Portfolios and Projects
Processes Hospital Output
Manage Cost Structure
care settings: SNF, HH, rehab, sub acute, in-patient psych
Direct patient care expenses: HPPD, OT, Registry, attendance
Other hospital expenses: Supplies, materials, non-patient care staff, attendance
Workplace Safety: Patient and non-patient care
EFFICIENCY
M di l C tSustained performance
30 Day readmission rates-HF reason
(12 month roll up)
1.0
3.0
5.0
7.0
9.0
Sept Oct Nov Dec Jan Feb Mar April
SCAL Regional SouthBay
SBAY 30 day HF readmission rates declining!Pre Work
StartedPDSA cycles
started
BEST inRegion!
% p
ts. R
eadm
itted
for H
F in
30
days
TCP Pilot Started
PharmacistRole restructuredTo focus on HF
Gap AnalysisComplete
RIMPre-workstarted
•Kick Off Mtg•PDSAs Started:
1. ConcurrentMed Rev
2. Pt ID/HH ref.
ReliableDesignWkshopPt. ID
Medical Center drivers and portfolioprioritized
Department scoped 90-120 day projects
Sustained performance