Transcript Faculty Mindwalk

Mexico City, Mexico
August 21, 2014
Making change at
scale
A model for systems improvement
Kedar S. Mate, MD
Senior Vice President
Agenda
The social and financial need for change & improve
Prevailing models for achieving better quality
The model for improvement as fundamental for change
Case studies of “how” to make it happen
The Social Need
Major Biomedical Successes
Vaccines
Antimicrobial therapy
Management of Ischemic Heart Disease
AMTSL for maternity
Oral rehydration therapy
Antiretroviral therapy for HIV infection
Treatment for Diabetes Mellitus
Advances in chemotherapy
Organ transplant
Geographic Variation: PCI per 1,000 Medicare
Beneficiaries
Dartmouth Atlas, 2011. Improving Patient Decision-Making in Health Care
The Institute of Medicine – 1999
44,000 to 98,000 deaths
per year in hospitals from
medical injuries
Using “IHI Global Trigger
Tool” – we estimate about
40 patient injuries per 100
admissions
What should we aim for?
Safe
Effective
Patient Centered
Timely
Efficient
Equitable care
…For Everyone
Institute of Medicine
March 2001
The Financial Need
9
Medicare Expenditure per capita 2010
Dartmouth Atlas, 2010
What do you get for $3000 Extra?
32% more hospital beds per capita
65% more medical specialists
75% more internists
Technically less evidence-based care
Overutilization – more hospital days, procedures, visits
Slightly higher mortality
Lower satisfaction with hospital care
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11
Universal healthcare coverage
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Universal quality coverage
Mate KS, Rooney A, Supachutikul A, Gyani G. Accreditation as a Path to Achieving
Universal Quality Health Coverage. 2014
13
12 actions to cross the threshold
Standard-setting & Accreditation
Professional Licensure
Enabling legislation
Measurement, benchmarking & feedback
Public reporting
Use of Information technology; HMIS; meaningful use
Large-scale improvement initiatives
Learning systems across public-private sector
Workforce development including improvement skills
Patient and consumer engagement
Responsive regulation
Payment or incentive mechanisms
Prevailing Models
Model I: Inspection & Elimination
Frequency
The
Problem
Quality
The Cycle of Fear
Increase
Fear
Stop the
Messenger
Micromanage
Filter the
Information
Fear poisons Improvement
Don Berwick
Frequency
Model 2: Continuous Improvement
“Every Defect is a Treasure”
Quality
Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in an
improvement?
Act
Plan
Study
Do
100K Lives
Case Studies
South Africa
21
IHI Framework for Execution
Focus on Execution
Build Will & Motivation
Harvest Best Ideas
The “100,000 Lives Campaign”
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The Campaign “Planks” -Six Changes That Save Lives
1. Deployment of Rapid Response Teams
2. Delivery of Reliable, Evidence-Based
3.
4.
5.
6.
Care for Acute Myocardial Infarction
Medication Reconciliation
Prevention of Central Line Infections
Prevention of Surgical Site Infections
Prevention of Ventilator-Associated
Pneumonias
23
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How It’s Done
Business as Usual
Meetings
Committees
Consensus
Broadcast info
Incident Command
Fast tempo
Adaptive in real time
Focus on logistics
Results: Ascension Health (71 hospitals)
Preventable Error
Reduction in rate
Pressure Ulcer
95%
Neonatal mortality
79%
Birth Trauma
74%
Ventilator-acquired pneumonia
Falls with serious injury
Blood-stream infections
56%
54%
32%
Ascension Hospital Mortality Reduction
CareScience Observed minus Expected Mortality Rate per 100 Discharges
Ascension Health System
-0.3000
Baseline
-0.5000
1,038 Mortalities
Avoided (Year 2)
-0.6000
374 Mortalities
Avoided
(9 mos. of Year 3)
-0.7000
1,412 Mortalities
Avoided Since
Baseline Period
-0.8000
Actual Monthly Difference
p-bar (Center Line for Difference)
LCL
Dec-05
Nov-05
Oct-05
Sep-05
Aug-05
Jul-05
Jun-05
May-05
Apr-05
Mar-05
Feb-05
Jan-05
Dec-04
Nov-04
Oct-04
Sep-04
Aug-04
Jul-04
Jun-04
May-04
Apr-04
Mar-04
Jan-04
Feb-04
Dec-03
Nov-03
Oct-03
Sep-03
Aug-03
Jul-03
Jun-03
May-03
-0.9000
Apr-03
Observed minus Expected Rate per 100 Discharges
-0.4000
UCL
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Principles for Large-Scale Change
Bold, compelling aim
Strong evidence-based set of practices
Clear description of how to implement them
Leadership support from the start
Incident command approach
HIV Infection in South Africa in 2007
1/3 of pregnant mothers
were infected with HIV
20% of babies were
infected with HIV during
pregnancy and delivery
50% of HIV+ babies died
in first year of life
Necessary Ingredients…
 Leadership/Policy: National Strategic Plan
 Access: 90% women attend ANCs; 84% deliver in facility
 Funding: $748 per capita, 8.7% of GDP
 Supply Chain: Widespread availability of ART
 Evidence-base: ACTG076, PHPT-2, HIVNET-012
 Workforce: 4.9 care givers / 1000 (WHO min 2.5)
 Missing: A strategy for change from local to national level
Social System: Collaborative
Government target:
Reduce HIV transmission to
<5% by 2011
Common Aim
Team
1
Collaborative
Organizer
Team
5
Use a
common data
framework
Team
4
Team
2
Team
3
Share ideas
Share
ownership
Mate KS, Ngubane G, Barker P. International Journal for Quality in Health Care 2013; pp. 1–8
Social System: Collaborative
Government target:
Reduce HIV transmission to
<5% by 2011
Distr
office
Distr
office
Team
1
Collaborative
Organizer
Team
4
Team
2
Distr
office
Team
5
Team
3
Distr
office
Distr
office
Reducing mother-to-child HIV transmission
14%
Health System/QI: QI
approach spread to 3 Districts
Policy: New protocol introduced:
HAART if CD4<350
12%
Health System/QI: HIV
testing>95% pregnant
women in all 3 Districts
10%
8%
6%
4%
2%
Health Systems/QI:
Starting mothers on HAART
reaches 90% in 3 Districts
Training/decentralization
Nurses at PC clinics
trained in providing ARVs
Sep-12
May-12
Jan-12
Sep-11
May-11
Jan-11
Sep-10
May-10
Jan-10
0%
Infant Mortality Rates
RATE OF INSTITUTIONAL DEATHS AMONG
0-1 1 MONTHS OLD INFANTS PER 1000 ADMISSIONS (BASED ON 132
HOSPITALS IN 7 REGIONS)
Rate
80
19.8% mortality
reduction
70
60
56.2
50
45.1
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Project Fives Alive! Program data, 2014
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
20
Jan-12
30
35
Principles for Large-Scale Change
Bold, compelling aim
Strong evidence-based set of practices
Clear description of how to implement them
Leadership support from the start
Incident command approach
Social system for spread
Timely, transparent, data
Focus on testing solutions
Emphasis on ideas from the front-lines
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IHI Framework for Execution
Focus on Execution
Build Will & Motivation
Harvest Best Ideas
Change is Hard
…but it is possible
Dan Heath, Switch: How to change things when change is hard
Thank you
Kedar S. Mate, MD
Senior Vice President, Institute for Healthcare Improvement
Assistant Professor of Medicine, Weill Cornell Medical College
Editorial Board, Joint Commission Journal on Quality & Patient Safety
20 University Road, 7th Floor
Cambridge, MA 02138
617-301-4800
[email protected]
@KedarMate
www.ihi.org
Our Mission:
To improve health and health care worldwide
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Build a Learning System that
Speeds Reform
Set bold aims
Know the hard count of what you are trying to improve
Build data systems for continuous learning: “war rooms”
Learn from patients & communities (co-production)
Respect the insights of the front-lines of care
Rely on the evidence-base and add to it
Choose a technical method for improvement & change
Align financial incentives to support continuous learning
Seek partnership with others who are avid learners