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A Quality Perspective on System ChangeHow can stakeholders drive the triple aim?

Central East LHIN SymposiumMay 14, 2009

Eileen Patterson, MCEDirector, Quality ImprovementOntario Health Quality Council

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OHQC Mandate – A Dual Role

An independent body, created by the Government ofOntario to:

• Report directly to Ontarians on the state of our publicly funded health system; and

• Support quality improvement

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Attributes of Quality & High Performing Health System

• Effective• Efficient• Equitable• Accessible• Safe• Patient-centred

• Focused on population health

• Integrated• Appropriately

resourced

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INSERT Bar Chart from report – page 91

Effectiveness:Underuse of Evidence-Based Practices

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Effectiveness –Chronic Disease Management

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Avoidable Complications With Better Management of DM, CAD

• 8,000 deaths / yr• 8,000 AMIs• 4,000 strokes• 1,200 revascularization procedures

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% of ED visitors who waited >= 2 hours for treatment, 2007

47 46

34

25

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119

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Ontario Canada Australia New Zealand UnitedKingdom

UnitedStates

Germany Netherlands

Perc

ent

Access

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IntegrationOpportunity to Improve Communication, Handoffs

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Population Health Screening Programs

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EfficiencyUnnecessary Tests

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Patient-CentredNeed to Improve Patient Engagement in Care

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How Should Central LHIN Stakeholders digest this Quality Report to drive

Triple AIM focus?

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Islands of Excellence are not enough!

New islands appear, others go,  but no overall real change

Ordinary Quality

Islands of excellence within sea of ordinary quality and safety

Transformed organization with high levels of 

quality and safety everywhere

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“The currency of leadership is attention.”

Ron HeifetzThe Challenge of Adaptive Leadership

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How Much Time Does the Board Spend on Quality?

• Quality focused boards – at least 25% of time on quality

• Try Board Agenda audits:ITEM Time spent % on Q Q time– A-budget 1 hr 0 0– B- 2 hrs 50% 1– C-diff 1 hr 100% 1

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Changing the old

Making the future attractive

Leadership for Improvement

Will Ideas ExecutionEstablish the Foundation

Setting Direction: Mission, Vision and Strategy

PULLPUSH

Source: Institute for Healthcare Improvement (IHI)

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TargetsHow will you know you have reached your targets?

Mental Health/Addictions

Seamless Care for Seniors

Chronic Disease Prevention & Management

Wait Times & Critical Care

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Target Setting

• Is your thinking:– … let’s aim to meet the provincial average?or – How many defects in what we do can we drive out?

• Consider best ever practice by leading site / institution anywhere

• Beware of “best region in Ontario” stats• Think of eventual zero defect goal• Consider decreasing defects by ½ on each QI project

iteration

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Big Dot Indicators• BIG DOTS help a board summarize overall quality

into a single, or small set of indicators

• Important way of managing information overload / indicator-itis

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Hypothetical Indicator Cascade

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Improvement Dashboard• Focus on small # of key aims• Remove the denominator – focus on harm• Plot with annotated run chart• Put a story to the data• Quality committee of Boards for more detail

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Putting Human Face to Datafor the Board

• Critical to building will for change• Respond to people, not just statistics

Ron T., 77 yrs

Catheter infxn

Art B., 83 yrs

Insulin wrong dose

John M, 68 yrs

Post-op infxn

Anna B., 76 yrs

Fall in ED, # hip

Jan B., 22 yrsPost-C-section infxn

Alice B., 73 yrsStage IV ulcer

Mamie S., 67 yrs

C. difficile

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Bringing Patient Stories to Board

• Increasingly recognized as best practice in governance– Start board meetings or quality Committees with patient

story• Use to illustrate systemic problems, identify recurrent

patterns leading to poor quality, increase Board’s will to drive improvement– Avoid use of story to micromanage or second-guess

clinical or mgt decisions to specific case

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1.1 Satisfy Our Patients D

eath

s pe

r 10

00 D

isch

arge

s

YrMon.

2006200620062006200520052005200520042004200420042003200320032003DecSepJunMarDecSepJunMarDecSepJunMarDecSepJunMar

40

35

30

25

20

15

10

Monthly12mo rolling rate

Variable

Inpatient Mortality

Benchmark

8/7/2006; Prepared by Immanuel St. Joseph's-Mayo Health System Quality Resources Department

Immanuel St. Joseph's

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After Setting Targets & Measures… How to Get There?

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What Does Your Portfolio of Projects Look Like?

• “This year every department or organization will do at least 2 QI projects per year”

Vs

Potential Islands of Excellence

Mobilize the energy for quality transformation• Map out all the drivers of quality in the Board’s big picture goal. • Pick projects that address each driver. • Prioritize by potential impact on Board’s big dots. • Assign managers, staff time, & targets for managers to meet. • Address hand-outs between areas as well as processes within areas

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QI Skills Development• Core skills needed throughout workforce

Act Plan

Study Do

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What Type of QI Capacity Do You Have?

• # of experts in QI science– IHI improvement advisor– ASQ certified QI professional– LEAN experts and 6 sigma green & black belts

• # of physician champions• General knowledge of QI throughout workforce

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Question:• What would it take to build the kind of QI capacity

in CE LHIN that you find in GE, Motorola, Jonkoping, Alaska Health, or leading health care institutions?

• Where could the $$ come from?

• How would we measure the pay back?

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Board Functions

• Set vision, targets & timeframes for system improvement

• Holding CEO accountable• Monitor progress to vision

– Dashboard indicators• Big picture strategies, investments to support

improvement towards vision– IT, QI skills / training

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Watch out for the 2009 Report !

2008 REPORT ON ONTARIO’S HEALTH SYSTEM QI Guides and Tools

Electronic version of Report and QI Guides and Tools available at

www.ohqc.ca