International Forum on Quality & Safety in Healthcare

1. International Forum on Quality & Safety in Healthcare Reducing Cost, Improving Quality: The Life Cycle Model for Sustainability Thursday, April 10, 2014 Lucy A. Savitz, Ph.D., MBA Intermountain Healthcare Katharine Luther, RN Institute for Healthcare Improvement

2. Key Points • Well done, quality improvement (QI) work is a core capacity for impacting cost and quality. • A learning organization recognizes that QI work is a part of the evidence chain in getting the right care to the right patient at the right time in an efficient manner. • Organizational capacity for change is sustained by strategically directed, collective QI efforts – requiring a critical mass to influence culture.

3. The Quality Challenge The Right Care For The Right Person At The Right Time Ensuring consistency in access and quality – but how have we impacted cost? Deming posits that good quality leads to lower costs. This has been demonstrated.

4. Care Delivery Falls Short of Efficiency Potential • Well-documented, massive variation in practices • High rates of inappropriate or unnecessary care • Unacceptable rates of preventable care-associated patient injury & death • A striking inability to do what we know works • Huge amounts of waste, spiraling prices, and limited access

5. Waste in Healthcare • Reducing waste in health care is key to affordable, high quality health care. • Nearly half of consumed resources represent potentially recoverable waste in U.S. hospitals (44%)

6. Case for Continuous Improvement Incorporating • Innovation • Disciplined Quality Improvement (QI) • Evaluation Critical to finding new designs and solutions to close the gaps and meet the goals of optimizing: • Patient experience • Health of the population • Controlling cost/reducing waste.

7. Need for a Healthcare System that Learns We require a sustainable system • That gets the right care to the right person at the right time and then • Captures the results for making improvements.

8. 21st Century Health Care Information-rich, patient-focused enterprises Information and evidence transform interactions from reactive to proactive (benefits and harms) Evidence is continually refined as a by-product of care delivery 21st Century Health Care Actionable information available – to clinicians AND patients – “just in time”

9. Challenges to QI Driving Change • Inadequate training in and/or appreciation for scientific process • Lack of expectation for rigor • Missing science of large scale change • Unclear or do not share big picture view

10. Batalden Rethinking Triple Aim Better Professional Development Better Health Better System Performance

11. Scientific Approach to QIIOM: Selker, H et al., October, 2011. • Clear, measurable process & outcomes goals • Basis in evidence • Iterative testing • Appropriate analytic methods • Documented results

12. QI: Role in Driving Evidence Base Quality Improvement Outcomes Research Clinical Effectiveness Program Evaluation Implementation Science Intervention Studies (Trials) Qausi- experimental Driving the science of change/innovation…

13. Science of Large-Scale ChangeMcCannon, Berwick, Massoud in JAMA, 298(16):1937-1939, 2007 Innovation in Health Care • Find or create practices (technologies) that are better than the prevailing ones • Build the evidence base in order to take to scale • Quickly make those improvements ubiquitous • Failure to deploy improved technologies and practices widely and quickly is a form of waste • Charge is to learn about the spread of innovations

14. Training as a Game Changer • Consider how we allocate training resources to drive rigorous QI • Is the QI training experience an isolated or action oriented, team-based experience? • Are teams held accountable to demonstrate application of training? • Have we trained a critical mass in our organization to create change and support a learning culture?

15. An Organization’s QI Learning Curve

16. Building Capacity • Slow beginning is characterized by small number of staff, largely engaged independently in training (reflective learning, hard to sustain) • Steep acceleration is characterized by growing numbers of trained staff, engaging in team-based training (pockets of change, threat of turnover, limited leadership support, & loss of momentum) • Plateau is reached when a critical mass of staff are trained and begin to apply learning as a strategically directed collective (cultural change in the way care is delivered that is sustainable)

17. Katharine Luther IHI Lead From the Bedside to the Balance Sheet: Engaging Front-Line and Finance Staff to Lower Costs and Drive Quality

18. Shaping Teams: IHI Integrated Model • Requires collaboration between quality, medicine, finance, patients, and researchers. • Draws on knowledge base and expertise across disciplines for a holistic approach. • “We need each other to make this work.”

19. Making It Work Examples to Complement Quality Perspective: Finance/economics staff shadowing in clinical settings • Establish a business advisory service with assigned portfolios • Dual reporting relationships Incorporating patient/family point of view. Caveats: • Trust and relationship building are key elements. • It takes the right kind of people.

20. Creating Capacity:Critical Mass Training Within Care Delivery Examples of… • Where it has been done: Intermountain Healthcare, Brent James • Where it is happening: HopitauxUniversitaire de Geneve (HUG) Pierre Chopard

21. We Need to Know More About • The impact of training… • On the cost and quality impact of individual project changes. • As a lever for routinizing QI into the culture of a clinic, hospital, or system of care. • In generating evidence to promote large-scale change. • For accelerating the spread of evidence-based interventions.

22. Professional Development Opportunities for Researchers • Academy Health Delivery System Science Fellowship Program is aimed at developing leaders in the field to conduct operationally meaningful research to support Triple Aim activities. http://www.academyhealth.org/Training/Training.cfm?ItemNumber=9295 • The Health Foundation Improvement Science Development Group is a network of international experts from disciplines within the field, working on the development of improvement science as an international discipline through the sharing of ideas and knowledge. http://www.health.org.uk/areas-of-work/improvement-science/improvement-science-development-group/

23. Your Challenge Moving Forward • Strategically plan and develop your learning journey for continuous improvement to impact cost, quality, and value. • Assess your organizational cultural needs and stage of learning for action planning. • Consider how to sustain past, present, and future culture change driven by training/educational investments.