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Culturein and Healthcare

What we knowWhat we assume

Where we must goBill Hippenmeyer

Allan Frankel

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Healthcare Today

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Sources:

1. Institute of Medicine: Kohn LTCJ, Donaldson MS. To err is human: building a safer health system.. Washington, DC: National Academy Press; 1999

2. Institute of Medicine: Smith M, Saunders R, Stuckhardt L, et al. Best Care at Lower Cost The Path to Continuously Learning Health Care in America Committee on the Learning

Health Care System in America.. Washington (DC): National Academies Press (US); 2013.

3. Office of the Inspector General: Adverse Events In Hospitals: National Incidence Among Medicare Beneficiaries, November 2010

4. JT James, A New Evidence Based Estimate of Patient harms Associated With Hospital Care. Journal of Patient Safety, 9(3)122-128, 2013.

400,000

Preventable deaths from medical errors annually

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35% occur in ERs

45% in Medical Offices

leading to 75k

hospitalizations

20% in Hospitals and elsewhere

4,000,000

Preventable adverse events annually

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Communication and Collaboration Failures - Care Fragmented

Institute of Medicine 2003

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Outcome

Large % of total payment

P4P MEASURE

Care Coordination

Intermediate Outcomes Moderate % of total payment

Process and Structure

Small % of total payment

Small Practices

Unrelated Hospitals

ORGANIZATIONAL DESIGN

Independent Practice Associations

Physician Hospital Organizations

Fully Integrated

Delivery Systems

Source: Shih, Commonwealth Fund 2008

Harder and Better

Easier and Worse

Full Population

Prepayment

Global Case

Rates

Medical Home

Payments

Fee for Service

BUNDLING

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Federal agencies: Environmental Protection Agency (EPA)Occupational Safety and Health Administration (OSHA) United States Department of Agriculture (USDA) Department of Defense (DOD) Department of Homeland Security (DHS) Department of Justice (DOJ) Department of Labor (DOL) Federal Trade Commission (FTC) Internal Revenue Service (IRS)

Department of Health and Human Services (DHHS): Agency for Healthcare Research and Quality (AHRQ) Centers for Disease Control and Prevention (CDC)Centers for Medicare and Medicaid Services (CMS)Food and Drug Administration (FDA) Health Resources and Services Administration (HRSA) Indian Health Services (IHS) National Institutes of Health Substance Abuse andMental Health Services Administration (SAMHSA) Office for Civil Rights (OCR) Office of Inspector General (OIG)

State Agencies:Departments of Health (State and Local) Boards of Medicine Licensing Boards for Allied Health Professionals Departments of Welfare Departments of InsuranceDepartments of Welfare Departments of Insurance

Private and Specialty Organizations:Accreditation Council on Graduate Medical Education American Board of Medical Specialties (ABMS) Association of Schools of Allied Health Professions (ASAHP) Education Commission for Foreign Medical Graduates Federation of State Medical Boards Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Accrediting Organization (DNV-GL)Liaison Committee on Medical Education (LCME) Medical Specialty Societies National Board of Medical Examiners (NBME) National Committee on Quality Assurance (NCQA)

U.S. Agencies that Affect Healthcare

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Classification of Diseases: ICD 9 to 10

20,000code sets

155,000code sets

Sprained ankle goes from 5 codes to 45

Angioplasty goes from 1 code to 1170

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Facts available per MD decision as genomics and complex care play an increasing role

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Diagnosable Disorders

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56% Of staff are not comfortable speaking

up about error [psychological safety]

55% Of staff indicate inadequate patient

handoffs and team communication

Teamwork and Burnout

54% Burnout rate in US healthcare1/4 nurses leave within 1 year of practice

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$3T GDP - Annual US Spend on Healthcare [17.4% of USGDP in 2014]1

$17BDirect Cost of Errors ,2011

$825BDirect and Indirect Financial Impact of Errors, using Quality Adjusted Life Years [QALY], 20122

Sources:

1. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html

2. Moreno et al, The Economics of Health Care Quality and Medical Errors. J Healthcare Finance, 39(10),2012

3. Shreve et al., The $17.1 billion problem: the annual cost of measurable medical errors,” Health Affairs, 30(4):596-60, 2011

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Medicare Payment Withholdings

$10.2BAnnual Medicare Withholdings

Safety &

OutcomesMortality

BSIs

UTIs

SSIs

US$M

At Risk

Patient

Experience Discharge Info

Pain

Communication

Efficiency $ Spent / Life

Clinical

Process SCIP, AMI, PN

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Withholds Pose Survival Challenges

Hospital Margins Rising Costs Challenges in Integration

2-3%

25%

61%

Avg operating margin

Have negative margins

Have declining margins

Doesn’t consider withholdings from private insurers

19% Expected margin drop

over next decade

Mergers & Acquisitions

[M&A] activity up 70%,

2010-2015

M&As increase healthcare

costs

Average Medicare

withholdings of $1.8M

per hospital

Central functions consolidating,

but care is decentralizing and

fragmenting

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How do we achieve sustainable safe and

reliable care?

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What does

do?

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Confidential & Proprietary

DON’T WE WANT TO INNOVATE TO REMOVE THE RISK?

CAN WE LEARN FROM OTHER INDUSTRIES & SECTORS?

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Innovation can’t be ordained. However, you can create an environment

where it will evolve organically

Self-Driving Car

Smart Contact Lens

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Susan WojcickiSenior VP, YouTube

Pillars of Innovation

Google confidential | Do not distribute

Think 10x

“If you want cars to run at 50 miles per

gallon, fine you can retool your car a

little bit.

But if I told you it has to run on a

gallon of gas for 500 miles...you have

to start over.”

Astro Teller

Engineering Director, Google X

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Work in small teams...

Google confidential | Do not distribute

FOCUS on the user experience...

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Be purposeful with the creative process

Launch and Iterate

Step 1 Step 2 Step 3 Step 4 Step 5

Understand and Observe

Synthesize Visualize Prototype, evaluate and refine

Implement

Scope the project. Learn first-hand about people and contexts of use.

Translating research insights into opportunities for design. Creating visible and

tangible experiences.

Improving design ideas by making them physical, so users can interact with them.

Supporting resolution of human issues in the first design.

Iteration is key to the creative process

Frictionlessly share ideas across your organization

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Tap into innovation from everywhere

CreateSpacesThat

Engage

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TEAMWORK IS AT THE HEART OF CHANGE

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Collaboration and Cultural Design in

HealthcareHow do we compare?

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SociotechnicalMaturity

Model

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Understand culture in a contextual framework

Transparency

Effective

Leadership

Psychological

Safety

Conflict

Resolution

Teamwork &

Communication

Just Culture

ReliabilityImprovement

&

Measurement

Continuous

Learning

Engagement of

Patients & Family

IHI and SRH

Culture

Learning

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SCORESafety, Communication, Organizational Risk and Reliability, Engagement(SRH’s Survey of Culture, Engagement, Burnout)

Teamwork Learning Environment

Sa

fety

Lo

ca

l L

ea

de

rsh

ip

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Work Setting

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Communication & Collaboration

The “Key” To Clinical, Operational And Financial Value

Predicted Outcome Lead Author Published In

Psychological Safety Leonard 2004

Cost Pronovost 2011

Adverse Events Pronovost / Pettker 2010 / 2009

Medication Errors Sutcliffe 2007

Re-Admissions Singer 2011

Surgical Outcomes Birkmeyer / Neily 2011 / 2010

Medical Malpractice Claims RAND Group 2010

Patient Safety Indicators Singer 2009

Adverse Event Reporting Katz-Navon 2005

Patient Satisfaction Hofmann 2006

Staff Burnout, Turnover Shanafelt 2015

Executive WalkroundsFrankel

Moreno

2003

2012

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Analog boards work …but have serious limitations

1. Manual effort = 10 hours per week

2. Data:

No automated input

No automated analytics

No automated sharing

No electronic sharing

No ability to aggregate

1. Must be physically present

2. Does not support communication

with other units or providers across

care continuum

3. Not configured to teach or make

improvement efforts intuitive and

easy

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Culture and Leaders

MI = Michigan

EWR = Executive WalkRounds

FB = Feedback

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MI = Michigan

EWR = Executive WalkRounds

FB = FeedbackEngagement and Leaders

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What makes an effective team?

1. Psychological safety

2. Dependability

3. Structure & Clarity

4. Meaning

5. Impact

Great teams can be measured

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Team hierarchy of needs

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“I think the response to mistakes on this team is consistently in the spirit of ‘gotta break eggs to make omelettes.’ ”

Teams: Psychological Safety

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Teams that feel safe beat their sales targets

TARGET SALES REVENUE

+17%

-19%

Unsafe team

Safe team

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Survey

On the five underlying dynamics of team

effectiveness

Report

Entire team reviewed

gTeams@Google

Discussion

Team set aside 90 minutes to talk through results

Action Planning

Consult resources to take action

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Talk to each other, from anywhere

Collaborate + share

Ask, measure, respond

Some of our simplest tools help us do this

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YOU are biased.(So am I.)

It matters.

Unbiasing

Get employees comfortable calling it out

Use group decision making to mitigate bias

Hold everyone accountable

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Google confidential | Do not distribute

"These three components of our

culture create a virtuous cycle of

attraction, community, engagement,

and innovation. If you give people

freedom, they will amaze you.

They’ll do remarkable things, and all

you need to do is give them a little

infrastructure and a lot of room to

change the world. And I think that

holds in any industry."

Laszlo Bock

Google’s SVP of People Operations

Confidential & Proprietary

1

(a few)

2

3

4

5

Don’t confuse development with

6

7

8

9

10

Hire only people who are better

Give your work meaning

Trust your people

managing performance

Focus on the two tails

Be frugal and generous

Pay “unfairly”

Nudge

Manage the rising expectations

Enjoy! And then go back to No. 1

than you

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Confidential & Proprietary

YOU CAN BE THE CATALYST TO CHANGE

Create room for innovation

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Exercise new muscles

Embrace new social paradigms

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Take some risk

Choose the right partners

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Create Big Ideas Focus on Execution Innovate & Disrupt

HYPOTHESIS: Engagement is the catalyst for innovation

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What next for Healthcare?

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1.Make culture visible.2.Understand culture in a contextual

framework.3.Engage Leaders, Train, Train, Train, and

expect.4.Act.

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ISSUES AIMS

Advancement, Growth and Job Basics

Emotional Exhaustion, Work Load Strain, Work Life Balance

Make culture visibleHierarchy of needs

Decision Making, Values, Voice

Teamwork Norms, Behaviors and Professionalism

Self Reflection, Error Reporting and the Collection of Defects

Learning: Action and Improvement

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ANY STAFFHas a voice

MANAGERA better manager

LEADERSConnected to frontline

Frontline caregiver Manager Quality &

Improvement

Leadership Physician

IMPROVEMENTInvolved

PHYSICIANSInvolved

Learning Environment Systems:Training, Expecting, Acting