Making change at scale

1. Mexico City, Mexico August 21, 2014 Kedar S. Mate, MDSenior Vice President Making change at scale A model for systems improvement

2. Agenda • The social and financial need for change & improve • Prevailing models for achieving better quality • The model for improvement as fundamental for change • Case studies of “how” to make it happen

3. The Social Need

4. Major Biomedical Successes • Vaccines • Antimicrobial therapy • Management of Ischemic Heart Disease • AMTSL for maternity • Oral rehydration therapy • Antiretroviral therapy for HIV infection • Treatment for Diabetes Mellitus • Advances in chemotherapy • Organ transplant

5. Geographic Variation: PCI per 1,000 Medicare Beneficiaries Dartmouth Atlas, 2011. Improving Patient Decision-Making in Health Care

6. The Institute of Medicine – 1999 • 44,000 to 98,000 deaths per year in hospitals from medical injuries • Using “IHI Global Trigger Tool” – we estimate about 40 patient injuries per 100 admissions

7. What should we aim for? Safe Effective Patient Centered Timely Efficient Equitable care …For Everyone Institute of Medicine March 2001

8. The Financial Need

9. Medicare Expenditure per capita 2010 Dartmouth Atlas, 2010

10. What do you get for $3000 Extra? • 32% more hospital beds per capita • 65% more medical specialists • 75% more internists • Technically less evidence-based care • Overutilization – more hospital days, procedures, visits • Slightly higher mortality • Lower satisfaction with hospital care

11. Universal healthcare coverage

12. Universal quality coverage Mate KS, Rooney A, Supachutikul A, Gyani G. Accreditation as a Path to Achieving Universal Quality Health Coverage. 2014

13. 12 actions to cross the threshold • Standard-setting & Accreditation • Professional Licensure • Enabling legislation • Measurement, benchmarking & feedback • Public reporting  • Use of Information technology; HMIS; meaningful use • Large-scale improvement initiatives • Learning systems across public-private sector • Workforce development including improvement skills • Patient and consumer engagement • Responsive regulation   • Payment or incentive mechanisms

14. Prevailing Models

15. Model I: Inspection & Elimination Frequency The Problem Quality

16. The Cycle of Fear Increase Fear Stop the Messenger Micromanage Filter the Information

17. Fear poisons Improvement Don Berwick

18. Model 2: Continuous Improvement“Every Defect is a Treasure” Frequency Quality

19. What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? Act Plan Study Do Model for Improvement

20. 100K Lives South Africa Case Studies

21. IHI Framework for Execution Focus on Execution Build Will & Motivation Harvest Best Ideas

22. The “100,000 Lives Campaign”

23. The Campaign “Planks” -- Six Changes That Save Lives • Deployment of Rapid Response Teams • Delivery of Reliable, Evidence-Based Care for Acute Myocardial Infarction • Medication Reconciliation • Prevention of Central Line Infections • Prevention of Surgical Site Infections • Prevention of Ventilator-Associated Pneumonias

25. Business as Usual Incident Command Fast tempo Adaptive in real time Focus on logistics How It’s Done • Meetings • Committees • Consensus • Broadcast info

26. Results: Ascension Health (71 hospitals) Preventable Error Reduction in rate Pressure Ulcer 95% Neonatal mortality 79% Birth Trauma 74% Ventilator-acquired pneumonia 56% Falls with serious injury 54% Blood-stream infections 32%

27. Ascension Hospital Mortality Reduction

28. Principles for Large-Scale Change • Bold, compelling aim • Strong evidence-based set of practices • Clear description of how to implement them • Leadership support from the start • Incident command approach

29. HIV Infection in South Africa in 2007 1/3 of pregnant mothers were infected with HIV 20% of babies were infected with HIV during pregnancy and delivery 50% of HIV+ babies died in first year of life

30. Necessary Ingredients… • Leadership/Policy: National Strategic Plan • Access: 90% women attend ANCs; 84% deliver in facility • Funding: $748 per capita, 8.7% of GDP • Supply Chain: Widespread availability of ART • Evidence-base: ACTG076, PHPT-2, HIVNET-012 • Workforce: 4.9 care givers / 1000 (WHO min 2.5) • Missing: A strategy for change from local to national level

31. Social System: Collaborative Government target: Reduce HIV transmission to <5% by 2011 Common Aim Share ideas Use a common data framework Share ownership Team1 Team 5 Collaborative Organizer Team4 Team2 Team3 Mate KS, Ngubane G, Barker P. International Journal for Quality in Health Care 2013; pp. 1–8

32. Social System: Collaborative Government target: Reduce HIV transmission to <5% by 2011 Distr office Distr office Team1 Team5 Collaborative Organizer Team 4 Team2 Distr office Distr office Team3 Distr office

33. Reducing mother-to-child HIV transmission Health System/QI: QI approach spread to 3 Districts Policy: New protocol introduced: HAART if CD4<350 Health System/QI: HIV testing>95% pregnant women in all 3 Districts Health Systems/QI: Starting mothers on HAART reaches 90% in 3 Districts Training/decentralizationNurses at PC clinics trained in providing ARVs

34. 19.8% mortality reduction Project Fives Alive! Program data, 2014 Infant Mortality Rates

35. Principles for Large-Scale Change • Bold, compelling aim • Strong evidence-based set of practices • Clear description of how to implement them • Leadership support from the start • Incident command approach • Social system for spread • Timely, transparent, data • Focus on testing solutions • Emphasis on ideas from the front-lines

36. IHI Framework for Execution Focus on Execution Build Will & Motivation Harvest Best Ideas

37. Change is Hard …but it is possible Dan Heath, Switch: How to change things when change is hard

38. Thank you Kedar S. Mate, MD Senior Vice President, Institute for Healthcare Improvement Assistant Professor of Medicine, Weill Cornell Medical College Editorial Board, Joint Commission Journal on Quality & Patient Safety 20 University Road, 7th Floor Cambridge, MA 02138 617-301-4800 kmate@ihi.org @KedarMate www.ihi.org

39. Our Mission:To improve health and health care worldwide

40. Build a Learning System that Speeds Reform • Set bold aims • Know the hard count of what you are trying to improve • Build data systems for continuous learning: “war rooms” • Learn from patients & communities (co-production) • Respect the insights of the front-lines of care • Rely on the evidence-base and add to it • Choose a technical method for improvement & change • Align financial incentives to support continuous learning • Seek partnership with others who are avid learners