Presentation on theme: "2014 Beardmore Lecture November 2014 Derek Feeley"— Presentation transcript:
1 2014 Beardmore Lecture November 2014 Derek Feeley Executive Vice PresidentInstitute 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!
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.”
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 purposeCompassionate governanceStay true to your values (especially in the toughest times)Change how you leadShare your power
16 Constancy of purpose Keep Quality as the business strategy Find the joy in workA human face behind every statistic
17 Quality as a Business Strategy Establish and communicate the purposeView the organization as a systemGet the right information for improvementIntegrate with business planningManage improvement activities
23 Burnout affects patients More mistakesLess adherence to physician adviceLess sympathyLess patient satisfaction
24 Statistics are people with the tears wiped away Sharenda W.2/15/09Med ErrorLoueene D.9/23/09FallBeverly S.2/4/09Med ErrorRobert D.5/12/09Post Procedure DeathKaren C.9/28/09Delay In TreatmentPeggy P.7/1/09BurnEdward R.4/23/09Wrong Side ProcedureBrenda R.10/14/09Delay In TreatmentJames H.10/25/09Post Procedure DeathLilliam C.4/3/09Retained foreign object47% Reduction SSER from Dec. 08 Baseline48% Reduction in # of events year to year24 Patients & Events – Jan-Dec,2009 vs 46 Total for 2008Donna S.6/4/09Retained foreign objectDorothy R.1/28/09Delay In TreatmentYoland C.7/7/09Delay in TreatmentJerry Y.11/7/09FallMonroe K.5/18/09Post Procedure DeathScott G.9/5/09Delay in TreatmentJuanita A.5/14/09Delay In TreatmentAlma M.11/6/09FallJohnny B.11/9/09FallRonnie D.11/3/09Delay in TreatmentWillie B.11/5/09Med ErrorPauline M.11/2/09FallMichael F.8/20/09Retained foreign objectHelen C.11/4/09Delay 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 judgmentJoy, not fearAn arm around the shoulder, not a ‘head on a plate’Bright spots not just defects
27 A little too soft for you? Complex adaptive systemsMultidisplinary teamsSocial network theoryReliability theoryDecision theoryLeadershipDiffusion of innovationsTheories of motivationSystemPsychologyMeasurementRegressionGraphical displays of dataStatistical process controlProgram evaluationOperational definitionsModel for improvementDesign of experimentsKnowledgeVariationDeming to the rescue!
28 “The First Law of Improvement” Every system is perfectly designed to achieve exactly the results it gets.
33 Some Basic PremisesMost 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 TargetNo action taken hereReject defectivesAction taken on all occurrencesQualityBetterOld Way(Quality Assurance)WorseQualityBetterWorseNew 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 worldHow do you motivate a nation to improve outcomes?
36 Bright spotsIn 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 malnourishedFed children twice a dayLet children feed themselvesPrincipal staple was riceSweet-potato greens associated with a stigma of being poorBright spotsFed children four times a dayActively fed children by spoon if neededAdded shrimp, crabs, and sweet-potato greens to the mealSource; 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 kidsSix months later 65% of kids nourishment status improvedSpread to 14 VillagesReached 265 villages and 2.2 million Vietnamese peopleSource: Dan Heath ; Switch 2010
39 Stay true to your values Especially when times are toughPerson-centered in word and deedNever ‘walk past’
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 togetherWe’re getting thereWork with engaged peoplePeople have the answersPeople control their livesDeficit Thinking:Problem orientatedHow to fix this problem?Someone needs to sort thisUs versus themProblems are embeddedDo things to peoplePeople are a problemPeople can’t be trusted to make decisions or be in control
49 Comfortable with complexity Leaders as “sense makers”Allow solutions to emergeBeware the “aye been”Accept paradox and contradiction
50 Share power (or bring back Mutuality!) Embrace co-productionCede power to get influenceRights and responsibilities
51 Organizations Learning from Patients The Old WayRyhov Hospital in Jönköping had traditional hemodialysis and peritoneal dialysis center.But in 2005, a patient, Christian, asked about doing it himself.
52 The New WayChristian taught a 73-yr-old woman how to do it… …and they started to teach others how to do it.
53 The New WayNow they aim to have 75% of patients to be on self-dialysisThey 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 staffManaging at 1/2 – 1/3 less cost per patientEvidence 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 leadShare 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.”