Imagine a land where…. A patients’ charter of rights and responsibilities is in place that includes waiting time guarantees. Over 90% of patients requiring elective care are treated within 18 weeks. 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. 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.
Share of hospital costs accounted for by administration 7 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.”
13 It can’t be like this, either..... The Choluteca Bridge, after Hurricane Mitch
All improvement is change (but not all change is improvement) 14 Change is inevitable (Except from vending machines)
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 15
Constancy of purpose Keep Quality as the business strategy Find the joy in work A human face behind every statistic 16
Quality as a Business Strategy 1. Establish and communicate the purpose 2. View the organization as a system 3. Get the right information for improvement 4. Integrate with business planning 5. Manage improvement activities 17
Burnout affects patients More mistakes Less adherence to physician advice Less sympathy Less patient satisfaction 23
Beverly S. 2/4/09 Med Error Dorothy R. 1/28/09 Delay In Treatment Sharenda W. 2/15/09 Med Error Edward R. 4/23/09 Wrong Side Procedure Robert D. 5/12/09 Post Procedure Death Donna S. 6/4/09 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 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 Lilliam C. 4/3/09 Retained foreign object Juanita A. 5/14/09 Delay In Treatment Yoland C. 7/7/09 Delay in Treatment Michael F. 8/20/09 Retained foreign object Peggy P. 7/1/09 Burn Loueene D. 9/23/09 Fall Karen C. 9/28/09 Delay In Treatment Brenda R. 10/14/09 Delay In Treatment James H. 10/25/09 Post Procedure Death Monroe K. 5/18/09 Post Procedure Death Alma M. 11/6/09 Fall Johnny B. 11/9/09 Fall Jerry Y. 11/7/09 Fall Willie B. 11/5/09 Med Error Pauline M. 11/2/09 Fall Ronnie D. 11/3/09 Delay in Treatment Scott G. 9/5/09 Delay in Treatment Helen C. 11/4/09 Delay In Treatment Statistics are people with the tears wiped away
Don Berwick 25 “The source of energy at work is not in control, it is in connection to purpose.”
Compassionate governance Learning, not judgment Joy, not fear An arm around the shoulder, not a ‘head on a plate’ Bright spots not just defects 26
System Psychology KnowledgeVariation Complex adaptive systems Multidisplinary teams Social network theory Reliability theory Program evaluation Operational definitions Model for improvement Design of experiments Decision theory Leadership Diffusion of innovations Theories of motivation Measurement Regression Graphical displays of data Statistical process control A little too soft for you? Deming to the rescue!
“The First Law of Improvement” Every system is perfectly designed to achieve exactly the results it gets. 28
Some Basic Premises 1. Most people are trying hard most of the time to do a job they can be proud of. 2. All improvement is change (though not all change is improvement). 3. Fear is an enemy of improvement. 4. You feel like this now…… 33
Quality Better Old Way (Quality Assurance) Quality BetterWorse New Way (Quality Improvement) Action taken on all occurrences Reject defectives Another way? Source: Robert Lloyd, Ph.D. Requirement, Specification or Target No action taken here Worse
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? 35
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. 36 Source; Dan Health; Switch 2010
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 37 Source; Dan Health; Switch 2010 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
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
Stay true to your values Especially when times are tough Person-centered in word and deed Never ‘walk past’
Interdependent dimensions of High-Impact Leadership 45 High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.
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; 2013. Available on www.ihi.org.
Assets vs. Deficits 48 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
Comfortable with complexity Leaders as “sense makers” Allow solutions to emerge Beware the “aye been” Accept paradox and contradiction
Share power (or bring back Mutuality!) Embrace co-production Cede power to get influence Rights and responsibilities
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.
The New Way Christian taught a 73-yr-old woman how to do it… …and they started to teach others how to do it.
The New Way Now they aim to have 75% of patients to be on self- dialysis They currently have 60% of patients
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.”
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.”
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.”
To recap Constancy of purpose Compassionate governance Stay true to your values (especially in the toughest times) Change how you lead Share your power
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.” Mahatma Gandhi