Leading Together

1. Leading Together UT System Clinical Safety and Effectiveness Conference October 27, 2011 Maureen Bisognano President and CEO IHI

2. Aims for Today • Look out at the challenges we share in the coming year • Look around for ideas and models • Look in and celebrate the amazing work you are doing

3. Our Challenges • Structural challenges in this time of reform • Health needs and challenges in the populations we serve • Managing the complexity in caring for patients

4. Making Sense of It All

5. Scores: Dimensions of a High Performance Health System * * * Note: Includes indicator(s) not available in earlier years. 5 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

6. HEALTHY LIVES Mortality Amenable to Health Care Deaths per 100,000 population* * Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. See Appendix B for list of all conditions considered amenable to health care in the analysis. Data: E. Nolte, RAND Europe, and M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files and CDC mortality data for U.S. (Nolte and McKee, 2011). 6 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

7. HEALTHY LIVES Infant Mortality Rate Infant deaths per 1,000 live births National average and state distribution International comparison, 2007 ^ Denotes years in 2006 and 2008 National Scorecards. Data: National and state—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003–2008; Mathews and MacDorman, 2011); international comparison—OECD Health Data 2011 (database), Version 06/2011. 7 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

8. QUALITY: EFFECTIVE CARE 8 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. Hospitals: Prevention of Surgical Complications Percent of adult surgical patients who received appropriate care to prevent complications* * See Appendix B for methods and description of clinical indicators. Data: IPRO analysis of data from CMS Hospital Compare.

9. QUALITY: COORDINATED CARE 9 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. Medications Reviewed When Discharged from the Hospital, Among Sicker Adults, 2008 Percent of hospitalized patients with new prescription who reported prior medications were reviewed at discharge Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized or had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom; US=United States. Data: 2008 Commonwealth Fund International Health Policy Survey.

10. QUALITY: SAFE CARE 10 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. Potentially Preventable Adverse Events and Complications of Care in Hospitals * Rates are adjusted by age, gender, age-gender interactions, comorbidities, and Diagnosis Related Group (DRG) clusters. Data: Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (retrieved from HCUPNet at http://hcupnet.ahrq.gov). 10

11. QUALITY: PATIENT-CENTERED, TIMELY CARE Difficulty Getting Care After Hours Without Going to the Emergency Room, Among Sicker Adults, 2008 Percent of adults who sought care reported “very” or “somewhat” difficult to get care on nights, weekends, or holidays without going to the emergency room Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized or had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom; US=United States. Data: 2008 Commonwealth Fund International Health Policy Survey. 11 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

12. Our Challenges • Structural challenges in this time of reform • Health needs and challenges in the populations we serve • Managing the complexity in caring for patients

13. Figure 1. Growth in the Number of People Age 65 and Older 450 404 400 377 20% 351 65+ 350 325 21% Under 65 20% 300 300 281 17% 13% 12% 249 250 227 Number (in millions) 13% 203 11% 200 10% 179 9% 151 80% 79% 150 132 8% 80% 84% 87% 123 7% 88% 106 5% 87% 5% 92 89% 100 90% 76 4% 91% 4% 92% 93% 95% 95% 50 96% 96% 0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 Note: The total population data for 1900 to 2000 include unknown age data. Therefore, the data used to determine the proportionof the population under age 65 and age 65 and older does not sum to equal the total population. Sources: 1900 to 2000 data are from Hobbs, F., & Stoops, N. (2002). Demographic Trends in the 20th Century (Census 2000 Special Reports, CENSR-4). Washington, DC: U.S. Census Bureau. Available at http://www.census.gov/prod/2002pubs/censr-4.pdf. 2010 to 2050 data are from Population Projections Program (2000). Projections of the Resident Population by Age, Sex, Race, and Hispanic Origin: 1999 to 2100 (MiddleSeries). Washington, DC: U.S. Census Bureau. Available at http://www.census.gov/population/www/projections/natdet.html. Source: R. Friedland and L. Summer, Demography Is Not Destiny, Revisited, The Commonwealth Fund, March 2005.

14. A Youth Bulge • The world is in a demographic transition – from high rates of fertility and mortality, to lower birthrates and longer lives. • But since mortality rates are falling before fertility rates are, a “youth bulge” results. • We need new designs to ensure the health of these growing populations.

15. Southcentral Foundation, Anchorage, AK The “Five Year Gestation”

16. Obesity Trends* Among U.S. AdultsBRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

17. Obesity Trends* Among U.S. AdultsBRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

18. Obesity Trends* Among U.S. AdultsBRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

19. Obesity Trends* Among U.S. AdultsBRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

20. Obesity Trends* Among U.S. AdultsBRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

21. Obesity Trends* Among U.S. AdultsBRFSS, 2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

23. The “Hot Spots” • “Super” utilizers of health services • 5% of patients account for 49% of US health spending • Patients at the end of life need improved palliative and hospice care

24. Our Challenges • Structural challenges in this time of reform • Health needs and challenges in the populations we serve • Managing the complexity in caring for patients

25. Increasing Complexity • In the mid 1970s, the average patient in a hospital required 2.5 staff FTEs for care… • …20 years later, the average patient needs 19.5 FTEs† • A physician today has over 13,600 possible diagnostic options and the opportunity to select from over 6000 prescription options in the US †Source: Atul Gawande, MD

26. The Path Forward • New ways to lead • Vibrant and important aims • More ways to learn

27. The Four Leadership Questions • Do you know how good you are? • Do you know where you stand relative to the best? • Do you know where the variation exists? • Do you know the rate of improvement over time?

28. New Leadership Skills • Structural • Leading With: • Patient-led design • Structural huddles • Gemba walks • Cultural changes • Safety • Harm • Patient-centered • Improvement and innovation • Spread strategy • Building capability Personal Leading Through: • Attention • Listening • Sensing • Learning • Action • Signs and symbols

30. Structured Huddles • A huddle is a “communication vehicle…a fast, focused, highly collaborative process.”† • Huddles should be frequent and short. • They enhance communication; generate and help manage knowledge; and help continuously improve care delivery. †Cooper, Robert L. Meara, ME. “The Organizational Huddle Process – Optimum Results Through Collaboration.” Health Care Manager: December 2002.

31. Huddlesat Cincinnati Children’s Hospital Medical Center

32. Gemba Walks

33. Ghana: Rapid scale-up of systems improvement across nation’s health facilities Project is ahead of schedule, with simultaneous spread in northern regions (NCHS and Ghana Health Service) and middle regions (NCHS hospitals Collaborative).

34. The Path Forward • New ways to lead • Vibrant and important aims • More ways to learn

35. Health of a Population Per Capita Cost Experience of Care

36. Health of a Population Per Capita Cost Experience of Care

37. Institute of Medicine’s Six Aims • Safe – no needless deaths • Effective– no needless pain or suffering • Patient-Centered – no helplessness in those served or serving • Timely– no unwanted waiting • Efficient– no waste • Equitable – for all

38. Patient-Centered Flow Patient demand is growing Our ability to safely and efficiently serve all patients depends on: Right Patient Right Place Right Time Right Care Team No Delays Most activity in the hospital is scheduled; urgent/emergent work is “predictable”

39. Flow and Safety • Inseparable initiatives in a hospital • Getting the “Rights” right • Right Bed, Nursing Care, Time, Plan, Treatment • No longer a passive system – best care requires active management of these critical aspects of the patients experience. • Best route to optimize the best care model is to control the variables in care delivery.

40. Initial Results of Re-Design • Weekday Waiting Times – 28% reduction in spite of a 24% increase in case volume • Weekend Waiting Times – 34% reduction in spite of a 37% increase in case volume • Throughput increase of 4.8% = 1OR room in a setting of 20 rooms • Overtime hours decreased by an estimated 57% between September 18, 2006 and the first week of January 2007. If OR operating costs are estimated at $250/room hour, then these savings are equivalent to $10,750/week, or $559,000 annually. • Overall growth sustained at ~7% / year for past two years, no additional operating rooms added

42. Greater Production Capacity Through Flow and Patient Placement – What Has it Meant? • Has allowed for an additional 78 patients per day to be treated within our current bed capacity that would not have been possible under “pre-flow improvement processes • Improved flow and patient placement have allowed us to avoid the construction of 102 additional beds ($100+ million) that would have been required to meet today’s volume in our FY2002 workflow system

43. Institute of Medicine’s Six Aims • Safe – no needless deaths • Effective– no needless pain or suffering • Patient-Centered – no helplessness in those served or serving • Timely– no unwanted waiting • Efficient– no waste • Equitable – for all

44. How do we make care more patient centered?

45. The Burden of the Illness

46. Innovation: 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.

47. The New Way • Christian taught a 73-yr-old woman how to do it… • …and they started to teach others how to do it.

48. The New Way • Now they aim to have 75% of patients to be on self-dialysis • They currently have 60% of patients

49. 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.”

50. 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.”