Collaborative Leadership to Promote Safety and Quality at the Point of Care

1. Collaborative Leadership to Promote Safety and Quality at the Point of Care Doug Salvador MD MPH Patient Safety Officer Maine Medical Center Salvad@mmc.org

2. Game Plan • Healthcare Reform • Clinical Microsystems • Collaboration • Leadership of improvement • Role of the CNL in microsystems improvement

3. What is Healthcare Reform? • Covering the uninsured • Slowing the rate of cost increase • Redesigning the care model • Patient rights and privacy • Electronic health records • Payment reform

4. Healthcare Reform • Reducing the unwarranted variations • Improving the health of the community • Redesigning the care model

5. Unwarranted Variation Variations that cannot be explained on the basis of illness, scientific evidence or well-informed patient preferences Preference- Sensitive Care “Involves trade-offs, (at least) two valid alternative treatments are available” Effective Care “Proven effectiveness, No significant trade-offs” Beta blocker use among patients post heart attack varies from 5%-92%, when it should be 100% In Southern California, a patient is 6 times more likely to have back surgery for a herniated disk than in New York City Supply Sensitive Care “If they build it You will come” Per-capita spending per Medicare enrollee in Miami, FL is almost 2.5 times as great as in Minneapolis, MN

6. Ratio of Rate in Highest to Lowest Spending Regions (risk-adjusted) 0.5 1.00 1.5 2.0 25 3.0 3.0 1.00 2.0 25 0.5 1.5 Effective Care (HEDIS measures) Reperfusion in 12 hours for AMI Aspirin at admission for AMI Mammogram, Women 65-69 Flu shot during past year, elderly Preference Sensitive Care Cataract Extraction Total Hip Replacement Total Knee Replacement Back Surgery Supply Sensitive Care Office Visits Inpatient Visits Initial Inpatient Specialist Consultations Chest X-ray Pulmonary Function Test Total Inpatient Days Inpatient Days in ICU or CCU Lower in High Spending Regions Higher in High Spending Regions

7. Relative Risk of Death Across Quintiles of Spending Q2 Q3 Q4 Q5 ColorectalCancer Q1 Q2 Q3 Q4 Q5 MyocardialInfarction Q1 Q2 Q3 Q4 Q5 Decreased Risk Increased Risk 1.00 1.05 1.10 0.95 Hip Fracture Q1 Q1 = Lowest spending HSA’s Q5 = Highest spending Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, and Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Annals of Internal Medicine, 2003. 138: 288-98. 0.95 1.00 1.05 1.10

8. The microsystem is where unwarranted variation is treated: increasing its use of effective care aligning care received with patient preferences understanding its utilization of supply-sensitive care. The Clinical Microsystem

9. Clinical Microsystem A clinical microsystem is a small group of people who work together to provide care to discrete sub-population of patients. It has shared clinical and business aims, linked processes, shared informational environment, and produces services which can be measured as outcomes.

10. Marjorie Godfrey Paul Batalden Gene Nelson

11. Goals of Clinical Microsystems at MMC • Train frontline staff in process improvement tools • Engage frontline in improvement work • Greater control of decisionmaking • Sense of ownership and joy in work • Establish a common improvement language • Create multidisciplinary forums for quality work • Make improvements to quality, clinical outcomes, and patient experience

12. Elements of a Comprehensive Quality Improvement Program • Leadership • Toolkit for Improvement • Capacity to train on the tools • Measurement and Feedback • Transparency • Systems Design • Accountability • Collaboration

13. Collaboration What does it mean to you?

15. Resources • Everyone complains that they have too few resources to redesign systems or improve quality • Successful collaboration taps into resources otherwise never considered. Effectively, it lights a fire and resources come out of the woodwork to contribute to the goals of the collaborative. • Transitions of care example.

16. Collaborative Leadership

17. Board Performance Improvement Committee NEC MEC Quality Council Performance Improvement Team Pt Safety Team Radiology Pediatrics Emergency Medicine Neurosciences Critical Care Services Oncology OB/GYN Cardiac Services AIM Surgical Services Anesthesia Psychiatry Vascular Center Joint Center, etc. Lab/Pathology

18. Learning Collaboratives

19. What is a Collaborative? • Multidisciplinary teams from different healthcare organizations or different parts of a single organization that meet together for a common specific improvement purpose. • learn together • learn from each others shared experience • share common improvement targets • share data

20. Obstacles Lack of: • Resources • Knowledge • Accurate information • Personal links and trust Philosophical differences Professional issues Staff/Organizational Changes Lack of: • Systems view • Support from leadership of member organization • Clear boundaries • Agreed upon goals Territorialism 20

21. Planning Considerations • Mission: agree on a clear purpose and goals • Membership: full multidisciplinary participation • Roles: clinical leader, project mgr, data analyst • Funding • Governance: multidisciplinary decisionmaking body • Contractual: Who owns data? Participant responsibilities • Meetings: location, length, format • Communication: regular updates, email, internet postings • Action models: the way we do improvement Ayers, et al. Quality Improvement Learning Collaboratives, Q Manage Health Care, 2005

22. MMC Clinical Microsystems Learning Collaborative

23. The Setup • RFA process to select teams • Requirements for: • Weekly meeting commitment • Learning sessions attendance • Physician and CNL team co-leaders • Medical Center provides: • Microsystems coach • Data support • Microsystems teaching

24. Microsystems Teams

25. Phase I Team Results

26. Team Highlights

27. Geriatrics

28. We aim to decrease the amount of time between the bed being booked and the patient’s arrival on P3CD to no more than an average of 90 minutes for admissions and transfers from an average of 220 minutes.

29. Critical Care

30. Our Purpose: to provide comprehensive, cost effective, high quality, and compassionate care of all adult patients and their families in the Critical Care Units. Global Aim: to improve the processes involved with the prevention of VAP in Critical Care Units at MMC. Specific Aim: to decrease the amount of time between the Readiness to Wean assessment by RT and extubation by 40% by July 1, 2009. Team Goals

31. Original PDSA Cycle #1 – RT/RN Driven Extubation AIM: • Decrease time to extubation • Increase RN involvement in process • Empower bedside caregivers to advocate for timely patient extubation Measures: • Reduction in mean time and range of breathing assessment to extubation time • Feedback about process from MD, RN, RT

32. Results – ASBA to Extubation TimeSCU & CICU Combined 57.2 % reduction in time Baseline Data Since start of PDSA Cycles Average decrease of 5.5 hrs Avg: 9.5 h Avg: 4 h

34. Summary • Healthcare Reform is about redesigning the care model • Success will require unprecedented degrees of collaboration and clinical leadership • At Maine Medical Center, clinical nurse leaders have performed the functions of team leaders, collaborators, and applied improvement science to improve care.

35. Collaboration References • Torres GW and Margolin FS, The Collaboration Primer, Health Education and Research Trust (HRET), 2003 • The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. (Available on www.IHI.org) • Ovretveit, et al. Quality collaboratives: lessons from research, Quality and Safety in Healthcare, 2002;11: 345-351. • Ayers LR, et al. Quality Improvement Learning Collaboratives, Quality Management in Healthcare, 2005;14(4):234-247.