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IOM's Quality Through Collaboration: Ya Sure, Minnesota Can Do That! Clint Mac. Kinney, MD, IOM's Quality Through Collaboration: Ya Sure, Minnesota Can Do That! Clint Mac. Kinney, MD, MS [email protected] com Duluth, Minnesota July 18, 2005

2005 Minnesota Rural Health Conference Topics for Today 1. A brief introduction to the 2005 Minnesota Rural Health Conference Topics for Today 1. A brief introduction to the Institute of Medicine’s Quality Through Collaboration: The Future of Rural Health 2. The healthcare landscape; why change is coming (whether we like it or not!) 3. The elusive (but oh-so-important) topic of organizational culture 4. The requisite of leadership 5. Patient safety is job one 6. Quality improvement follows on safety’s heels 2

2005 Minnesota Rural Health Conference 3 Committee on the Future of Rural Health Care 2005 Minnesota Rural Health Conference 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

2005 Minnesota Rural Health Conference Five-Pronged Strategy 1. Addressing personal and population health needs 2005 Minnesota Rural Health Conference Five-Pronged Strategy 1. Addressing personal and population health needs 2. Establishing a quality improvement support structure 3. Strengthening human resources 4. Providing adequate and targeted financial resources 5. Utilizing information and communications technology 4

2005 Minnesota Rural Health Conference IOM’s 30, 000 -Foot View • Written from a 2005 Minnesota Rural Health Conference 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 5

2005 Minnesota Rural Health Conference The Healthcare Landscape –We do whacky things –Questionable healthcare 2005 Minnesota Rural Health Conference The Healthcare Landscape –We do whacky things –Questionable healthcare value –Pay for performance –Provider accountability 6

2005 Minnesota Rural Health Conference 7 Glitches Happen Oops. Uh, sorry about scratching your 2005 Minnesota Rural Health Conference 7 Glitches Happen Oops. Uh, sorry about scratching your truck.

2005 Minnesota Rural Health Conference Every system is perfectly designed… Look! It only takes 2005 Minnesota Rural Health Conference Every system is perfectly designed… Look! It only takes one guy and one ladder to change a light bulb! (Timber!) 8

2005 Minnesota Rural Health Conference 9 …to achieve the results that it yields. Ouch! 2005 Minnesota Rural Health Conference 9 …to achieve the results that it yields. Ouch! (or maybe) D’ Oh!!

2005 Minnesota Rural Health Conference Healthcare Safety Strategy? 10 2005 Minnesota Rural Health Conference Healthcare Safety Strategy? 10

2005 Minnesota Rural Health Conference The Healthcare Landscape –We do whacky things –Questionable healthcare 2005 Minnesota Rural Health Conference The Healthcare Landscape –We do whacky things –Questionable healthcare value –Pay for performance –Provider accountability 11

2005 Minnesota Rural Health Conference Healthcare Value = Quality + Service Cost 12 2005 Minnesota Rural Health Conference Healthcare Value = Quality + Service Cost 12

2005 Minnesota Rural Health Conference Healthcare Value (Quality) The Quality of Health Care Delivered 2005 Minnesota Rural Health Conference Healthcare Value (Quality) The Quality of Health Care Delivered to Adults in the United States – Mc. Glynn 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 13

2005 Minnesota Rural Health Conference Healthcare Value (Service) Press Ganey National Database. Presented at 2005 Minnesota Rural Health Conference Healthcare Value (Service) Press Ganey National Database. Presented at Health. Leaders Forums. 2005. 14

2005 Minnesota Rural Health Conference Healthcare Value (Cost) Causes of poor care: Misuse, underuse, 2005 Minnesota Rural Health Conference Healthcare Value (Cost) Causes of poor care: Misuse, underuse, overuse, waste – Juran Institute and Midwest Business Group on Health. 2003 15

2005 Minnesota Rural Health Conference Healthcare Value (Cost) Harris Interactive Poll (quoted by Steve 2005 Minnesota Rural Health Conference Healthcare Value (Cost) Harris Interactive Poll (quoted by Steve Wetzell, 2005) 16

2005 Minnesota Rural Health Conference The Healthcare Landscape –We do whacky things –Questionable healthcare 2005 Minnesota Rural Health Conference The Healthcare Landscape –We do whacky things –Questionable healthcare value –Pay for performance –Provider accountability 17

2005 Minnesota Rural Health Conference Pay for Performance • Developing force for change – 2005 Minnesota Rural Health Conference 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 18

2005 Minnesota Rural Health Conference 19 P 4 P - The Social Democrats • 2005 Minnesota Rural Health Conference 19 P 4 P - 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

2005 Minnesota Rural Health Conference P 4 P - The Darwinians • “If you 2005 Minnesota Rural Health Conference P 4 P - 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 20

2005 Minnesota Rural Health Conference The Healthcare Landscape –We do whacky things –Questionable healthcare 2005 Minnesota Rural Health Conference The Healthcare Landscape –We do whacky things –Questionable healthcare value –Pay for performance –Provider accountability 21

2005 Minnesota Rural Health Conference Accountability Agents 22 2005 Minnesota Rural Health Conference Accountability Agents 22

2005 Minnesota Rural Health Conference New Paradigm “No margin – no mission” to “No 2005 Minnesota Rural Health Conference New Paradigm “No margin – no mission” to “No outcome – no income” – Charles Denham National Patient Safety Foundation 23

2005 Minnesota Rural Health Conference Questions About the Future • Should rural healthcare providers 2005 Minnesota Rural Health Conference 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? 24

2005 Minnesota Rural Health Conference Cornerstones of Success Safety and Quality Patient Experience Community 2005 Minnesota Rural Health Conference Cornerstones of Success Safety and Quality Patient Experience Community Health Financial Stability Employee Growth 25

2005 Minnesota Rural Health Conference Culture What does “culture” mean to you? 26 2005 Minnesota Rural Health Conference Culture What does “culture” mean to you? 26

2005 Minnesota Rural Health Conference Culture • Culture is the invisible force behind the 2005 Minnesota Rural Health Conference 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 27

2005 Minnesota Rural Health Conference Cultural Barriers to Safety We have not seen substantial 2005 Minnesota Rural Health Conference 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 28

2005 Minnesota Rural Health Conference 29 The “Worstest” Cultural Barrier Because we’ve ALWAYS done 2005 Minnesota Rural Health Conference 29 The “Worstest” Cultural Barrier Because we’ve ALWAYS done that way! it Thanks to Sharon Vitousek, MD North Hawaii Outcomes Project and IHI

2005 Minnesota Rural Health Conference Defining Mission 30 2005 Minnesota Rural Health Conference Defining Mission 30

2005 Minnesota Rural Health Conference Cultural Determinants • Walking the Mission talk? • The 2005 Minnesota Rural Health Conference 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? 31

2005 Minnesota Rural Health Conference Performance Improvement • Performance improvement is key to an 2005 Minnesota Rural Health Conference 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) 32

2005 Minnesota Rural Health Conference 33 Mission/Reality Conundrum Provided by Tim Size Rural Wisconsin 2005 Minnesota Rural Health Conference 33 Mission/Reality Conundrum Provided by Tim Size Rural Wisconsin Health Cooperative

2005 Minnesota Rural Health Conference Leadership What does “leadership” mean to you? 34 2005 Minnesota Rural Health Conference Leadership What does “leadership” mean to you? 34

2005 Minnesota Rural Health Conference IOM’s Comments on Leadership • Finding – Rural communities 2005 Minnesota Rural Health Conference 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. 35

2005 Minnesota Rural Health Conference Leaders’ Roles • Establish direction • Align people • 2005 Minnesota Rural Health Conference 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 36

2005 Minnesota Rural Health Conference Seeking “Balance” • Seek balance among equally important (and 2005 Minnesota Rural Health Conference Seeking “Balance” • Seek balance among equally important (and often competing) priorities – Mission, Operations, Budget, and the 3 Rs – Quality, Patients, Employees, and Finance • With balance, “no margin; no mission” becomes circular and meaningless 37

2005 Minnesota Rural Health Conference Leadership Action List q Scan the external environment and 2005 Minnesota Rural Health Conference Leadership Action List q Scan the external environment and select cultural priorities q Align strategy, operations, and measures q Encourage behaviors that support a safety and quality culture q Mandate a non-punitive work environment q Build improvement capability q Remember: Attention is the currency of leadership 38

2005 Minnesota Rural Health Conference CEO Action List q Implement patient safety survey q 2005 Minnesota Rural Health Conference CEO Action List q Implement patient safety survey q Select a PI champion, but never abdicate responsibility q Communicate new cultural emphases – again and again q Oversee improvement aims at highest leadership levels q Manage with data q Reorganize meeting structure q Drive down decision-making q Engage physicians 39

2005 Minnesota Rural Health Conference QI Director Action List q Make Quality more than 2005 Minnesota Rural Health Conference QI Director Action List q Make Quality more than a department q Categorize quality work for optimal efficiency q Develop a performance tracking system q Choose pertinent quality measurements q P–D–S–A q Seek opportunities (glitches!) for improvement q Communicate and celebrate 40

2005 Minnesota Rural Health Conference How Not to Start Meetings and Memos “We need 2005 Minnesota Rural Health Conference 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. ” 41

2005 Minnesota Rural Health Conference Safety and Quality 42 2005 Minnesota Rural Health Conference Safety and Quality 42

2005 Minnesota Rural Health Conference Safety and Quality • Safety and Quality? • Organizational 2005 Minnesota Rural Health Conference Safety and Quality • Safety and Quality? • Organizational Culture? • Both! 43

2005 Minnesota Rural Health Conference Culture for Quality to Flourish • Active leadership and 2005 Minnesota Rural Health Conference 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 44

2005 Minnesota Rural Health Conference Attracting/Retaining the Right People • Selective hiring and credentialing 2005 Minnesota Rural Health Conference 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 45

2005 Minnesota Rural Health Conference In-House Quality Improvement Processes • Identify where suboptimal care 2005 Minnesota Rural Health Conference 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 46

2005 Minnesota Rural Health Conference Right Tools • Information technology and QI staff to 2005 Minnesota Rural Health Conference 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 47

2005 Minnesota Rural Health Conference Communication 48 2005 Minnesota Rural Health Conference Communication 48

2005 Minnesota Rural Health Conference 49 Communication – The First and Last Defense GLITCH 2005 Minnesota Rural Health Conference 49 Communication – The First and Last Defense GLITCH INJURY

2005 Minnesota Rural Health Conference New Communication Strategies • Handoff / handover – “Never 2005 Minnesota Rural Health Conference 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. 50

2005 Minnesota Rural Health Conference Quality Improvement Strategies • Assess variation • Care protocols 2005 Minnesota Rural Health Conference Quality Improvement Strategies • Assess variation • Care protocols • Care maps • 100 k Lives Campaign – Rapid Response Team – AMI care – Surgical site infection – Adverse drug events – Central line infection – Ventilator pneumonia 51

2005 Minnesota Rural Health Conference In Support of the Cornerstones • Define and engender 2005 Minnesota Rural Health Conference In Support of the Cornerstones • Define and engender improvement • Lead and facilitate change • Support and nurture the organization The cornerstones become your vision • • • Safety and Quality Patient Experience Financial Stability Employee Growth Community Health 52

2005 Minnesota Rural Health Conference Changes 53 2005 Minnesota Rural Health Conference Changes 53

2005 Minnesota Rural Health Conference Goal: Healthy Communities 54 2005 Minnesota Rural Health Conference Goal: Healthy Communities 54