1. 2014 Beardmore Lecture November 2014 Derek Feeley
Executive Vice President
Institute for Healthcare Improvement

2. Gail, insert updated IHI Strategy on a page
Gail – We’re going to start at the top and walk you through the core facts and messages and how this all fits together.
Based on great feedback from many of you and the continued development of our dual approaches to the mission of improved Health and Health Care worldwide, our strategy-on-a-page now looks like this.
While visually it looks different, the core elements haven’t really changed. Here’s what we altered:
The two prongs of the strategy remain the same except that we added the word partner to the right to reflect that we don’t just innovate improvements but we partner to harvest and spread bright spots.
For each of the prongs of the strategy, we provide a list of what it will take to achieve success.
Replaced the 5 boxes with our focus areas and brief descriptions with our familiar graphic. We then added a line of text about how each will contribute to the transformation of health care in the upper left. (Why? Cleaner, more parallel structure to what now appears on the right, leaves our main focus areas and core competencies together as our way of delivering on these promises across both the improvement of health care and the improvement of health.)
On the right we added the 6 requirements to create a culture of health.

3. A view from over the pond
Scotland is one of the leading health care systems in the world!

4. Commonwealth Fund Study

5. Imagine a land where….
Citizens can access the most appropriate member of their primary care team within 48 hours.
Up-to-date statistics and reports on wait times and health system performance indicators are publicly available.
Over 90% of patients are seen within four hours in the emergency department.
Over 98% of in-patient procedures and day-surgery cases are treated within 12 weeks of agreement to treat.
Over 90% of patients requiring elective care are treated within 18 weeks.
A patients’ charter of rights and responsibilities is in place that includes waiting time guarantees.
Imagine a land where:
• A patients’ charter of rights and responsibilities is in place that includes wait-time guarantees.
• Over 90% of patients requiring elective care are treated within 18 weeks: from referral by a family physician to start of treatment/procedure including all diagnostic testing and specialist consultations.*
• Over 98% of in-patient procedures and day-surgery cases are treated within 12 weeks of agreement to treat.
• Over 90% of patients are seen within four hours in the emergency department (i.e., admitted, transferred or discharged).
• Citizens can access the most appropriate member of their primary care team within 48 hours.
• Up-to-date statistics and reports on wait times and health system performance indicators are publicly available.
In addition to providing timely access, this land has been successful in improving other dimensions of quality of care (e.g., significantly reducing levels of hospital acquired infections, reducing the level of inappropriate care), and performance in all of these dimensions is being tracked through the measurement and reporting of performance targets available for use by patients, providers and system managers alike.
Fortunately, this land already exists — Scotland.

6. this land already exists
Fortunately,
this land already exists

7. Share of hospital costs accounted for by administration
United States; 25.3%
Netherlands; 19.8%
England; 15.5%
Wales; 14.3%
Canada; 12.4%
Scotland; 11.6%
Himmelstein et al, Health Affairs, September 2014
“Among the UK nations, Scotland’s administrative costs were lowest, England’s were highest and Wales’ were in between. This ranking correlates roughly with the role of market mechanisms in those nations’ health care systems.”

8. Ground-breaking

9. Ground-breaking

10. However. . . . Politics Economics Demographics Epidemiology
Social determinants of health
Changing expectations
Workforce

11. We need a sustainable method

12. So, what’s the plan?
1993 5:1 -- “Everyone has a plan until they get punched in the mouth.” Mike Tyson or John Shirley.
The Thomas W. Lawson was the only seven-masted, steel-hulled schooner originally planned for the Pacific trade, but then used primarily to haul coal and oil along the East Coast of the United States. Built in 1902, the ship holds the distinction of being the largest schooner and the largest pure sailing ship (without an auxiliary engine) ever built.
100 years ago: The Thomas W. Lawson was destroyed near the Scilly Isles Hellweather's Reef, in a storm on December 14, 1907, killing all but two of her 18 crew including the pilot who was already aboard ship. All seven masts broke off and fell into the sea with all seamen who had climbed up the rigging for safety on their captain's command.
The lesson: Most of healthcare is dealing with the imperative to Our reliability will not increase by adding more masts, by trying harder, by studying harder – we must find a new approach of we want the headline, if we watnt to reach escape velocity.
At a cost of approximately $250,000, the Thomas W. Lawson holds the record of being the only seven-masted schooner.
Her design and purpose was an ultimately unsuccessful bid to keep sailing ships competitive with the steam ships that were becoming more common for freight transport purposes.
The schooner was smashed starboard side on against Shag Rock near Annet, England by tremendously heavy seas after having grounded the dangerous underwater rocks.

13. It can’t be like this, either. . . . .
The Choluteca Bridge, after Hurricane Mitch

14. All improvement is change (but not all change is improvement)
Change is inevitable
(Except from vending machines)

15. 5 keys to thrive in a changing world
Constancy of purpose
Compassionate governance
Stay true to your values (especially in the toughest times)
Change how you lead
Share your power

16. Constancy of purpose Keep Quality as the business strategy
Find the joy in work
A human face behind every statistic

17. Quality as a Business Strategy
Establish and communicate the purpose
View the organization as a system
Get the right information for improvement
Integrate with business planning
Manage improvement activities

18. A strategy and a roadmap

19. Welcome to IHI

20. Joy Gratitude Hope Awareness of abundance
Deep satisfaction from serving others

23. Burnout affects patients
More mistakes
Less adherence to physician advice
Less sympathy
Less patient satisfaction

24. Statistics are people with the tears wiped away
Sharenda W.
2/15/09
Med Error
Loueene D.
9/23/09
Fall
Beverly S.
2/4/09
Med Error
Robert D.
5/12/09
Post Procedure Death
Karen C.
9/28/09
Delay In Treatment
Peggy P.
7/1/09
Burn
Edward R.
4/23/09
Wrong Side Procedure
Brenda R.
10/14/09
Delay In Treatment
James H.
10/25/09
Post Procedure Death
Lilliam C.
4/3/09
Retained foreign object
47% Reduction SSER from Dec. 08 Baseline
48% Reduction in # of events year to year
24 Patients & Events – Jan-Dec,2009 vs 46 Total for 2008
Donna S.
6/4/09
Retained foreign object
Dorothy R.
1/28/09
Delay In Treatment
Yoland C.
7/7/09
Delay in Treatment
Jerry Y.
11/7/09
Fall
Monroe K.
5/18/09
Post Procedure Death
Scott G.
9/5/09
Delay in Treatment
Juanita A.
5/14/09
Delay In Treatment
Alma M.
11/6/09
Fall
Johnny B.
11/9/09
Fall
Ronnie D.
11/3/09
Delay in Treatment
Willie B.
11/5/09
Med Error
Pauline M.
11/2/09
Fall
Michael F.
8/20/09
Retained foreign object
Helen C.
11/4/09
Delay In Treatment

25. Don Berwick
“The source of energy at work is not in control, it is in connection to purpose.”

26. Compassionate governance
Learning, not judgment
Joy, not fear
An arm around the shoulder, not a ‘head on a plate’
Bright spots not just defects

27. A little too soft for you?
Complex adaptive systems
Multidisplinary teams
Social network theory
Reliability theory
Decision theory
Leadership
Diffusion of innovations
Theories of motivation
System
Psychology
Measurement
Regression
Graphical displays of data
Statistical process control
Program evaluation
Operational definitions
Model for improvement
Design of experiments
Knowledge
Variation
Deming to the rescue!

28. “The First Law of Improvement”
Every system is perfectly designed to achieve exactly the results it gets.

29. The simple, wrong answer
Blame somebody!

30. Answer #2 – Bad Apples
Frequency
The Problem
Better Quality Worse

31. Filter the Information
The Cycle of Fear
Increase Fear
Kill the Messenger
Filter the Information
Micromanage

32. Mid Staffs coding of palliative care vs HSMR

33. Some Basic Premises
Most people are trying hard most of the time to do a job they can be proud of.
All improvement is change (though not all change is improvement).
Fear is an enemy of improvement.
You feel like this now……
Added animation

34. Action taken on all occurrences
Another way?
Requirement, Specification or Target
No action taken here
Reject defectives
Action taken on all occurrences
Quality
Better
Old Way
(Quality Assurance)
Worse
Quality
Better
Worse
New Way
(Quality Improvement)
Source: Robert Lloyd, Ph.D.

35. Bright spots: Vietnamese children and Jerry Sternin
Prior to 1990, Vietnam had one of the worst levels of malnutrition in the world
How do you motivate a nation to improve outcomes?

36. Bright spots
In 1990, Jerry Sternin was asked to open an office for Save the Children in Vietnam.
With a $50k budget, he was tasked with fixing malnutrition for children across the country.
He started with 1 village.
Sternin recruited mothers who were ‘motivated.’
Identified bright spots among the malnournished.
Source; Dan Health; Switch 2010

37. The bright spots: what was different?
Norms among malnourished
Fed children twice a day
Let children feed themselves
Principal staple was rice
Sweet-potato greens associated with a stigma of being poor
Bright spots
Fed children four times a day
Actively fed children by spoon if needed
Added shrimp, crabs, and sweet-potato greens to the meal
Source; Dan Health; Switch 2010

38. Bright Spots- Vietnam The start- 4 mothers as Bright Spots
Spread to 50 malnourished families with mother’s in groups of 10 getting together to cook meals and feed kids
Six months later 65% of kids nourishment status improved
Spread to 14 Villages
Reached 265 villages and 2.2 million Vietnamese people
Source: Dan Heath ; Switch 2010

39. Stay true to your values
Especially when times are tough
Person-centered in word and deed
Never ‘walk past’

40. Truly person-centered

41. Don’t walk past

42. Don’t walk past

43. Change how you lead You will be wrong The leader as sense-maker
Comfortable with complexity and generous with power

44. You will be wrong

45. Interdependent dimensions of High-Impact Leadership
High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; Available on

46. High-Impact Leadership Behaviors What leaders do to make a difference
High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; Available on

47. IHI High-Impact Leadership Framework
High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; Available on

48. Assets vs. Deficits Assets Thinking: Strengths based
How can we create community spirit?
What can I do?
We’re all in this together
We’re getting there
Work with engaged people
People have the answers
People control their lives
Deficit Thinking:
Problem orientated
How to fix this problem?
Someone needs to sort this
Us versus them
Problems are embedded
Do things to people
People are a problem
People can’t be trusted to make decisions or be in control

49. Comfortable with complexity
Leaders as “sense makers”
Allow solutions to emerge
Beware the “aye been”
Accept paradox and contradiction

50. Share power (or bring back Mutuality!)
Embrace co-production
Cede power to get influence
Rights and responsibilities

51. Organizations Learning from Patients
The Old Way
Ryhov Hospital in Jönköping had traditional hemodialysis and peritoneal dialysis center.
But in 2005, a patient, Christian, asked about doing it himself.

52. The New Way
Christian taught a 73-yr-old woman how to do it… …and they started to teach others how to do it.

53. The New Way
Now they aim to have 75% of patients to be on self-dialysis
They currently have 60% of patients

54. Lessons to Date From Christian (patient):
“I have a new definition of health.”
“I want to live a full life. I have more energy and am complete.”
“I learned and I taught the person next to me, and next to her. The oldest patient on self-dialysis is 83 years old.”
“Of course the care is safer in my hands.”

55. Lessons to Date From Anette (nurse leader):
Surprised at design differences between patients, family, and staff
Managing at 1/2 – 1/3 less cost per patient
Evidence of better outcomes, lower costs, far fewer complications and infections
“We brought in the county’s employment, helped the patients make or update the CVs, and trained them for a new career.”

57. And today?
Now calculated costs at 50% of costs in other hemo-dialysis units.
Complications dramatically reduced and subsequent expensive care avoided.
Measuring success by “number of patients working.”

58. To recap Constancy of purpose Compassionate governance
Stay true to your values (especially in the toughest times)
Change how you lead
Share your power

59. The heart, the soul and the act
A nation’s culture resides in the hearts and in the soul of its people.
Mahatma Gandhi
“It's the action, not the fruit of the action, that's important. You have to do the right thing. It may not be in your power, may not be in your time, that there'll be any fruit. But that doesn't mean you stop doing the right thing. You may never know what results come from your action. But if you do nothing, there will be no result.”