IOM's Quality Through Collaboration: Ya Sure, Minnesota Can Do That!

1. IOM's Quality Through Collaboration: Ya Sure, Minnesota Can Do That! Clint MacKinney, MD, MS clintmack@cloudnet.com Duluth, Minnesota July 18, 2005

2. Topics for Today • A brief introduction to the Institute of Medicine’s Quality Through Collaboration: The Future of Rural Health • The healthcare landscape; why change is coming (whether we like it or not!) • The elusive (but oh-so-important) topic of organizational culture • The requisite of leadership • Patient safety is job one • Quality improvement follows on safety’s heels

3. Committee on the Future of Rural Health Care • Quality Through Collaboration: The Future of Rural Health • Institute of Medicine’s Quality Chasm Series • Available at www.nap.edu • Executive Summary (.pdf) is free • Five-pronged strategy to address rural healthcare quality challenges • Key findings and recommendations

4. Five-Pronged Strategy • Addressing personal and population health needs • Establishing a quality improvement support structure • Strengthening human resources • Providing adequate and targeted financial resources • Utilizing information and communications technology

5. IOM’s 30,000-Foot View • Written from a national perspective. • Recommendations for federal policy. • Challenge is to “bring it down” to local levels. • Emphasis today – How we can improve: • Culture • Leadership • Safety and Quality

6. The Healthcare Landscape • We do whacky things • Questionable healthcare value • Pay for performance • Provider accountability

7. Glitches Happen Oops. Uh, sorry about scratching your truck.

8. Every system is perfectly designed… Look! It only takes one guy and one ladder to change a light bulb! (Timber!)

9. …to achieve the results that it yields. Ouch! (or maybe) D’ Oh!!

10. Healthcare Safety Strategy?

11. The Healthcare Landscape • We do whacky things • Questionable healthcare value • Pay for performance • Provider accountability

12. Healthcare Value Value = Quality + Service Cost

13. Healthcare Value (Quality) The Quality of Health Care Delivered to Adults in the United States – McGlynn et al Results • Participants received 54.9% of recommended care. • 45% defect rate! Conclusions • The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. NEJM. Volume 348:2635-2645. June 26, 2003. Number 26

14. Healthcare Value (Service) Press Ganey National Database. Presented at HealthLeaders Forums. 2005.

15. Healthcare Value (Cost) Causes of poor care: Misuse, underuse, overuse, waste – Juran Institute and Midwest Business Group on Health. 2003

16. Healthcare Value (Cost) Harris Interactive Poll (quoted by Steve Wetzell, 2005)

17. The Healthcare Landscape • We do whacky things • Questionable healthcare value • Pay for performance • Provider accountability

18. Pay for Performance • Developing force for change • Approximately 100 programs • 1/3 commercial plans • Impacting both hospitals and physicians • Does it work? • Improved quality • Decreased utilization • Success seems to depend on size and type of incentive Int J Qual Health Care. 2000:12:133-42

19. P4P - The Social Democrats • A rising tide lifts all boats • Broad participation is important • Set achievable goals to start • Reward improvement as well as performance • Technical assistance to help all groups succeed Steve Wetzell. The Movement Towards Transparency and Pay for Performance. 2005. Healthcare providers “need payment not for performance, but to support performance.” – Don Berwick, 2005

20. P4P - The Darwinians • “If you build it, they will come” • Set the bar high • No breakthrough without pushing • Make threshold more difficult over time • Poor performers will (should) get consolidated Steve Wetzell. The Movement Towards Transparency and Pay for Performance. 2005. Accelerating change

21. The Healthcare Landscape • We do whacky things • Questionable healthcare value • Pay for performance • Provider accountability

22. Accountability Agents

23. New Paradigm “No margin – no mission” to “No outcome – no income” – Charles Denham National Patient Safety Foundation

24. Questions About the Future • Should rural healthcare providers feel complacent with cost-based reimbursement, grant funding, and minimal quality reporting mandates? • Are we in rural insulated and immune from the forces of healthcare change? • Should our patients continue to tolerate healthcare overuse, underuse, and misuse? • Should our patients continue to tolerate suboptimal safety, quality, and service?

25. Cornerstones of Success Safety and Patient Quality Experience Community Health Financial Employee Stability Growth CULTURE

26. Culture What does “culture” mean to you?

27. Culture • Culture is the invisible force behind the intangibles and observables in any organization, a social energy that moves people to act. Culture is to an organization what personality is to the individual – a hidden yet unifying theme that provides meaning, direction, and mobilization.* • What we believe; what we do * Kilman, Sexton, Serpa, 1985

28. Cultural Barriers to Safety We have not seen substantial progress in one critical area – culture – that has the greatest potential to produce sustainable improvements in safety. – Daniel Stryer and Carolyn Clancy BMJ. March 12, 2005 Why isn’t health care demonstrably safer? … The answer is to be found in the culture of medicine – complexity, autonomy, fear, and lack of leadership. – Lucian Leape and Donald Berwick JAMA. May 18, 2005

29. The “Worstest” Cultural Barrier Because we’ve ALWAYS done it that way! Thanks to Sharon Vitousek, MD North Hawaii Outcomes Project and IHI

30. Defining Mission

31. Cultural Determinants • Walking the Mission talk? • The congruence of: Mission – Operations – Budget – 3 Rs • Questions for home: • How do day-to-day operations support the Mission? • How does the budget prioritize the Mission? • How many staff and Board meetings are devoted to the Mission? • How are employees reinforced, recognized, and rewarded for living the Mission?

32. Performance Improvement • Performance improvement is key to an improvement culture • The Zen of performance improvement • “In God we trust… All else show data” (Michael Pugh) • “You can’t manage what you can’t measure” (unknown) • “Not all that counts can be counted and not all that is counted counts” (Albert Einstein) • “The world is not black and white; its grayness makes life interesting and often challenging” (me)

33. Mission/Reality Conundrum Provided by Tim Size Rural Wisconsin Health Cooperative

34. Leadership What does “leadership” mean to you?

35. IOM’s Comments on Leadership • Finding • Rural communities engaged in health system redesign would likely benefit from leadership training programs. • Recommendation • Skills sets such as coalition building, community engagement, health status measurement, change agency are necessary for transformational change. IOM. 2004. Quality Through Collaboration: The Future of Rural Health. Washington, D.C. National Academies Press.

36. Leaders’ Roles • Establish direction • Align people • Motivate and inspire • Plan and budget • Organize and staff • Control and problem-solve* • Measure, reflect, improve, and communicate *Kotter, 1990

37. Seeking “Balance” • Seek balance among equally important (and often competing) priorities • Mission, Operations, Budget, and the 3Rs • Quality, Patients, Employees, and Finance • With balance, “no margin; no mission” becomes circular and meaningless

38. Leadership Action List • Scan the external environment and select cultural priorities • Align strategy, operations, and measures • Encourage behaviors that support a safety and quality culture • Mandate a non-punitive work environment • Build improvement capability • Remember: Attention is the currency of leadership

39. CEO Action List • Implement patient safety survey • Select a PI champion, but never abdicate responsibility • Communicate new cultural emphases – again and again • Oversee improvement aims at highest leadership levels • Manage with data • Reorganize meeting structure • Drive down decision-making • Engage physicians

40. QI Director Action List • Make Quality more than a department • Categorize quality work for optimal efficiency • Develop a performance tracking system • Choose pertinent qualitymeasurements • P – D – S – A • Seek opportunities (glitches!) for improvement • Communicate and celebrate

41. How Not to Start Meetings and Memos “We need to improve morale around here – any of you boneheads have a good idea?” “The beatings shall continue until attitudes improve.”

42. Safety and Quality

43. Safety and Quality • Safety and Quality? • Organizational Culture? • Both!

44. Culture for Quality to Flourish • Active leadership and personal involvement • Explicit quality mission and quality targets • Regular performance reporting and accountability • Safe environment for reporting errors Meyers, JA et al. Hospital Quality: Ingredients for Success – Overview and Lessons Learned. The Economic and Social Research Institute. The Commonwealth Fund. #761. July 2004

45. Attracting/Retaining the Right People • Selective hiring and credentialing • Respect and empowerment of nurses • “Hire for attitude, train for aptitude” • Getting the “right” people on the bus (Jim Collins) Meyers, JA et al. Hospital Quality: Ingredients for Success – Overview and Lessons Learned. The Economic and Social Research Institute. The Commonwealth Fund. #761. July 2004

46. In-House Quality Improvement Processes • Identify where suboptimal care is delivered • Adequately staffed QI – lead by physicians • Deficiencies inspire discovery and correction • Evidence-based protocols • Team-based care management Meyers, JA et al. Hospital Quality: Ingredients for Success – Overview and Lessons Learned. The Economic and Social Research Institute. The Commonwealth Fund. #761. July 2004

47. Right Tools • Information technology and QI staff to abstract • Investing and developing culturally sensitive information technology • Physicians supported to develop guideline consensus • External training, peer networking, conferences Meyers, JA et al. Hospital Quality: Ingredients for Success – Overview and Lessons Learned. The Economic and Social Research Institute. The Commonwealth Fund. #761. July 2004

48. Communication

49. Communication – The First and Last Defense GLITCH INJURY

50. New Communication Strategies • Handoff / handover • “Never leave your wingman” • SBAR briefing strategy • Situation • Background • Assessment • Recommendation • Appropriate Assertion • Critical language • Huddle and Debriefing Leonard, M., et al. Achieving Safe and Reliable Healthcare: Strategies and Solutions.Health Administration Press. Ann Arbor, Michigan. 2004.