Linking Quality to Health Care’s “2nd Curve”

1. Linking Quality to Health Care’s “2nd Curve” From Innovation to Transformation: Delivering and Sustaining Results Institute of Public Administration of Canada Quality Healthcare Network Minto Suites Hotel Ottawa, Ontario 21 January 2011 Martin D. Merry, MD, CM Adjunct Associate Clinical Professor of Health Management and Policy University of New Hampshire Faculty, American College of Physician Executives Faculty, Center for Healthcare Governance, American Hospital Association

2. An Invitation “No problem can be solved from the same level of consciousness that created it. We must learn to see the world anew.” - Albert Einstein

3. 1st 2nd

4. 1st Curve Founders: “The Four Doctors” Halsted Kelly Osler Welch

5. “The most important event in the history of American and Canadian medical education”

6. 1912 : The 'Great Divide' "... for the first time in human history, a random patient with a random disease consulting a doctor chosen at random stands a better than 50/50 chance of benefitting from the encounter." Harvard Professor L. Henderson (Harris, Richard. A Sacred Trust. New York, NY: New American Library, 1966)

7. 2 Historical Curves of Health Care Innovation (derived from Kuhn, Toffler, Morrison, Merry) Future Performance (Second Curve/ 6+ Sigma) First Curve/ 4 sigma “Crossing the Chasm” (Craft+Information-Age Culture )     Circa 1910 (Craft-Age Culture) Performance (Bifurcation curve: 2011) Time             -

8. 1st Curve Health Care’s Performance Problem 1st Curve Health Care (Craft Culture) 90% OK 100,000 95% OK 50,000 99% OK 10,000

10. 1st Curve Legacy Medical errors as 5th-8th leading cause of death in US 44,000 – 98,000 deaths annually

11. May 25, 2004: We learn that Canada, too, is “infected.”

12. The 21st Century/ 2nd Curve Flexner Report?

13. Columns 2 & 3 = 2nd Curve Columns 2+3 = 2nd Curve

14. What we MUST understand: The emergence of 2nd Curve Health Care represents a Management, not Clinical paradigm shift. This fact has huge implications for leaders at all levels of the organization.

15. Evidence-based medicine Clinical protocols “Disease-Line” Management Rapid cycle PDCA Lean Six Sigma IT:EHR, Telehealth Clinical Microsystem Design Team-based care New models of System-Community relationships Community health innovation Strength based change (e.g., Appreciative Inquiry) Health Care’s beginning ascent of its 2nd Curve: Re-designing care systems around those served – while restoring the “joy of practice” to caregivers How 2nd Curve Is Happening

16. Our Structural Heritage, 1917-2011 Our structural “fatal flaw” Board of Trustees  Medical Staff Executive Committee Chief Executive Officer  Medical Staff Functions (“Silo 1”) Hospital Functions (“Silo 2”) • Credentialing • Departmental (Peer) Review • Surgical Case Review • Blood UR • Drug Usage Review • Pharmacy and Therapeutics • Medical Records • Nursing • Ancillary • Laboratory • Radiology • Physiotherapy • Risk Management • Finance, Planning • Regulatory Agencies • Etc. Management:Departments Physicians:Specialties 2011: The Structure  Hierarchy, Fragmentation, Communication gaps, Misunderstanding, Power Struggles, etc.

17. Fast Forward: Community Memorial Hospital, Menomonee Falls, Wisconsin

18. COMMUNITY MEMORIAL HOSPITALMenomonee Falls, Hospital Board Women & Children Care Primary Care Hospital Administration Medical Executive Committee Obstetrics, Gynecology, Perinatology,Pediatrics, Neonatology Internal Medicine, Medical Specialties, Family Practice, Hospitalist, Psychiatry, Emergency Medicine* Management and Coordination of Care Performance Improvement Teams / Cardiopulmonary Care Cardiology, Cardiothoracic Surgery, Pulmonology, Vascular Participation Leadership Orthopedics, Podiatry, Neurosurgery, PM&R, Radiology* Musculoskeletal Care Management Design Collaborative Practice Patient/ Community Clinical Microsystems Credentialing Caregivers Performance Improvement General Surgery, Surgical Specialties, Anesthesia* Radiation Oncology, Medical Oncology, Pathology* Surgical Care Cancer Care * Specialties provide care in all service lines K:\S\wp\7350(953)\misc\janice8.ppt

20. Patients and Families as Part of the Care Team

21. “Seek first to understand, then to be understood.” - Stephen Covey

23. Evolved around medical and hospital practices Disease focus, one patient at a time Hierarchical, physician controlled Performance problems assumed as people-caused “Culture of blame” Fragmentation of care givers and health care functions, “hand-off” gaps common Medical records paper, frag-mented, “owned” by caregiver Complexity  frequent errors, harm to patient Quality is compliance-oriented, 2-4 sigma common Reactive to “sentinel events” Designed around patient/ community, population need Health, prevention focus, patient plus population Team-based systems outperform hierarchy Recognition that performance problems 95% systems-based “Just Culture” Integration of all system elements, care “seamless” for patients EHR, “smart cards” owned by patients Integration of “quality sciences” minimizes error, harm Quality, value oriented toward 6+ sigma, O preventable harm Pro-active, Resilience-led 1st Curve2nd Curve

25. Senge’s “Five Disciplines” • Personal Mastery • Mental Models • Team Learning • Shared Vision • Systems Thinking (1st Curve health care, for all of its positives, focused almost solely on “Personal Mastery.” As many have shared at the meeting, all five disciplines are essential to “Learning Organizations.,” and the 2nd Curve.)

26. As John Maynard Keynes once noted . . . • “The hardest thing is not to get people to accept the new ideas, it is to get them to forget the old ones.” • Or, as Max Planck, a pioneering 20th Century physicist once remarked, “Scientific progress moves forward, one funeral at a time.”

27. “Command & Control” Pyramid (Taylorism, circa 1900) Top Management  Commands Hint: Doesn’t Work Anymore Obedience

28. The “New Leadership:”Creating Context “Farmers don’t grow crops; they create conditions under which crops can grow.” - Stephen Covey • Question: In my leadership role, am I creating a “fertile field” for a) the growth of modern quality/safety practice and b) a fundamentally different form of top-down/bottom up collaboration?

29. “Stewardship/Servant Leadership” (Covey, Block, others) Those We Serve Caregivers/Innovation Resources/ Support Top Management

31. The ThedaCare Breakthrough • “Realizing that ThedaCare needed change, leaders tried one improvement program after another over the course of many years. Most of the programs offered incrementally better results for a while, until everyone slid back into old habits.” Finally . . Leaders started thinking about breaking down the divisions between caregivers’ specialties, divisions of labor and habits of working to create a unified focus on the patient. Because this would require change in everyone involved, it was clear that hospital units needed a revolution instead of isolated, incremental adjustments.”

32. Today’s Leader Today’s leader is not someone who knows all the answers…or who makes decisions and gives orders in the old military model of leadership. Rather, the new leader is someone who can assess a situation, bring people together, build consensus, and discover solutions, building on the talents of everyone involved. The new leader is a facilitator, a communicator, a team builder. - Diane Dreher, The Tao of Personal Leadership

33. 2nd Curve Best of 1st Curve Aviation

34. 6+ sigma! merrymd@comcast.net Thank You! There are many ways to ascend Mt. Washington – auto road, cog railway, and many hiking trails. My best wishes to you Leaders on Ontario Health Care as you ascend your path toward 6 sigma health care!