kaiser permanente's large scale implementation of performance improvement

Kaiser Permanente’s Large Scale Implementation of Performance Improvement

Lisa Schilling, RN MPH, VP, Healthcare Performance Improvement

WCBF Lean Six Sigma and PI in Healthcare Summit

New Orleans, LA

May 12, 2011

2

Top

dow

n

Red

uce

varia

tion

Learning system

• Economic and social context for change

• Models of workplace learning

• Team performance

• Define organizational needs • Create system view• Plan/ manage improvement

• Align with strategy • ID drivers and portfolios • Build capability to improve

• Engaging the hearts and minds of the front line

• Creating “line of sight” to strategic goals

• Define high performing unit-based teams

Bottom

up

Learning and improvem

ent

High Performing Organizations Build Culture and Capability

Principles What we “do”

© Kaiser Permanente 2010 reproduce by permission only

3

Big Aim

We will be recognized by our members, payers, and employees as the safest, most effective and personal health care delivery system in the country.

Strategy

Dashboard

Targets


From Strategy to Execution

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HOW: Mortality & Inpatient Effectiveness Driver


6

Quality Goals Timeline – 2011 – 2013

Domain 2011 2012 2013

Population HealthSelf perceived health status data

for 15% of membersSelf perceived health status data

for 20% of membersSelf perceived health status data

for 25% of members

Population Care Management - Chronic Conditions

Medicare Stars Part C 4 StarsHEDIS composite at 90th percentile

All CV, diabetes, and cancer screening metrics at 90th percentile

Behaviorial Health, Musculoskeletal 90%Medication Management 75%

Medicare Stars Part C 4 StarsAll CV, diabetes, and cancer screening

metrics at 90th percentileBehaviorial Health, Musculoskeletal and

respiratory @ 90%Medication Management 75%

Medicare Stars Part C 4 StarsAll CV, diabetes, and cancer screening

metrics at 90th percentileBehaviorial Health, Musculoskeletal and

respiratory @ 90%Medication Management 90%

Inpatient HSMR TJC Composite

Reduce HSMR: Below US Medicare average, crude mortality 10% from 2010

baselineTJC Composite at national 90th percentile

Readmit rate<15% of all cause readmissions

Reduce HSMR: Below US MedicareTBD - May shift to inpatient outcomes

Readmit rate<10% of all cause readmissions

TJC Composite at national 90th percentile

Reduce HSMR: Below US MedicareTJC Composite at national 90th percentile

Patient Safety Never Events

10% less events than 2010 10% less events than 2011 10% less events than 2012

Workplace Safety Per regional targets Per regional targets Per regional targets

Clinical RiskManagement

0 to 5% reduction in lawsuits with a payout from 2010



Service Hospital

Outpatient

HealthPlan

Medicare Stars

At National 75th percentile (final quarter)

75th percentile in local or national in 3 of 8 regions


4 Stars on Overall CAHPS

At national 75th percentile (rolling 12 months)


75th percentile in local or national 7 of 8 regions

4+ Stars on Overall CAHPS

Above National 75th percentile (rolling 12 months)

8 of 8 Regions at goal

8 of 8 regions at goal

4+ Stars on Overall CAHPS

Equitable CareIdentify interventions to

reduce the gapDecrease the gap by x%

Decrease by x% more over 2012


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Aligning Strategy: Data to Monitor Variation

Range 85% - 95%

Range 94% - 98%

The Joint Commission Index Across Hospitals: Demonstrated Progress in Reducing Variation

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Our system is based on the attributes of high performing organizations

Best qualityBest service

Most affordableBest place to

work

KP needs to build capability in these six areas in order to achieve breakthrough performance


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Kaiser Permanente’s Performance Improvement System

AIM: Assist regions and facilities in developing, testing and implementing a

KP-wide performance improvement system that builds the capacity to

execute on high priority initiatives in each KP region by 2010.


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page 10

Achieve Breakthrough goals

Manage Local Improvement

Develop Human Resources

Spread and sustainProvide Leadership forLarge system Projects

Provide Day-to-DayLeaders for Micro Systems

Reduce HSMR and Achieve 90th National

Percentile on Joint Commission Index

No Needless Harm

Appropriate Care Setting

Preventable Complications

Preventable Deterioration

Preventable Harm Events

Big Q Targets Primary Drivers Secondary Drivers

Capacity in Alternative Setting

Primary Care Plan-End of Life

Population Based Programs

Trigger Tools (IHI)

Infection Reduction

SCIP (TJC)

Rapid Response

Teams (5 mil)

Escobar Predictive Modeling

(KP)

AMI Bundle (5 mil, TJC)

CHF Bundle(5 mil, TJC)

Pneumonia (TJC)

Medication Reconciliation (5 mil, TJC)

Never Events

Pressure Ulcers (5 mil)

High Alert Meds(5 mil)

Evidence-Based Population Care

Region/KPPO•Manage collaborative spread•Knowledge management•Consult critical initiatives•PI training

Region/Service Area/Local•Mission critical, high priority initiatives

Expert

Expert

Facility

TPL

TPL

TPL

TPL

TPL

TPL

Ops improvementresource

Expert

Expert

Experts

OperationalLeaders

(Executives)

ChangeAgents

(Middle Managers, Stewards, project leads)

Everyone

(Staff, Supervisors,

UBT lead triad)

Unit Based Teams

SharedKnowledge Continuum of PI Knowledge and Skills

Deep Knowledge

Many People Few People

Quality Goals TimelineDomain 2008 2009 2010

Reduce HSMR X%Reduce HSMR X%Reduce HSMR X%

National 90th percentileThree-quarters of way

between national average and 90th percentile

90th percentile

No Measure less than 75th Percentile

90th percentile

No Measure less than 75th

Percentile

90th percentile

No Measure less than 75th

Percentile

Ambulatory CareHEDIS

ZeroZeroZeroSafety (Never Events)

5% reduction in claims from 2009

5% reduction in claims from 20085% reduction in claims from

2007Clinical Risk Management

TBDLong term goal under development

Proposed: At or above 75% local or National MarketService

TBDTBDTBDResource Stewardship

TBDTBDN/AEquitable Care

Halfway between national average and 90th percentile

InpatientMortality Ratio

TJC Composite Index

1

DRAFT

Execution in KP’s System

Source: IHI 2008


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Lets look at the far left side: Manage local improvement

Moving from a project by project mentality to looking at system level improvement (end to end process with sequencing)

Creating clear lines of accountability and oversight Insure the right portfolio of initiatives to assure ourselves that we are doing enough to move the Big Dot

Reduce HSMR and Achieve 90th National

Percentile on Joint Commission Index

No Needless Harm

Appropriate Care Setting

Preventable Complications

Preventable Deterioration

Preventable Harm Events

Big Q Targets Primary Drivers Secondary Drivers

Capacity in Alternative Setting

Primary Care Plan-End of Life

Population Based Programs

Trigger Tools (IHI)

Infection Reduction

SCIP (TJC)

Rapid Response

Teams (5 mil)

Escobar Predictive Modeling

(KP)

AMI Bundle (5 mil, TJC)

CHF Bundle(5 mil, TJC)

Pneumonia (TJC)

Medication Reconciliation (5 mil, TJC)

Never Events

Pressure Ulcers (5 mil)

High Alert Meds(5 mil)

Evidence-Based Population Care

Region/KPPO•Manage collaborative spread•Knowledge management•Consult critical initiatives•PI training

Region/Service Area/Local•Mission critical, high priority initiatives

Expert

Expert

Facility

TPL

TPL

TPL

TPL

TPL

TPL

Ops improvementresource

Expert

Expert


12

Building Improvement Capability

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We can build our capacity to improve by developing our skills

Delivering Improvement Advisor through front line skills development program focused on 4 audiences

Using common language for the organization based on MFI, Lean, six sigma

Aligning executive through front line capability by matching infrastructure with new skills

Experts

OperationalLeaders

(Executives)

ChangeAgents

(Middle Managers, Stewards, project leads)

Everyone


UBT lead triad)

Unit Based Teams

SharedKnowledge Continuum of PI Knowledge and Skills

Deep Knowledge


page 6

Achieve Breakthroughgoals

Manage Local Improvement

Develop Human Resources

Spread and sustainProvide Leadership forLarge system Projects

Provide Day-to-DayLeaders for Micro Systems

Source: API 2006


14

Experts Operational

Leaders (Executives)

ChangeAgents

(Middle Managers, Stewards,

project leads)

Everyone


UBT lead triad)

Continuum of PI Knowledge and Skills

Deep Knowledge


Our approach will be to make sure that each group receives the knowledge and skill sets they need

when they need them and in the

appropriate amounts.

A key operating assumption of

building capacity is that different groups of people will have different levels of

need for PI knowledge and skill.

Content: What Skills Do We Need?

SharedKnowledge


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On-boarding

Dev

elo

p a

nd

Tes

t th

e

Sys

tem

at

a

Fac

ilit

y le

vel

Developing deeper capability to achieve big results over time

Exp

and

Im

pro

vem

ent

sys

tem

to

all

fa

cili

ties

Dee

pen

im

pro

vem

ent

kno

wle

dg

e w

ith

in f

acil

itie

s

September 2008 June 2009 2010 & 2011

Wave 2

Waves of Improvement Institute

Learning and sharing systems regionally and program-wide Improvement Institute

Wave 3Wave 4 & beyond

Implementation ExpansionContinuous

ImprovementComplete

We are here

Level of Project

Difficulty

• All Regions• 500 IA’s• 15 internal faculty

Mentors• 3,000+ Operations

Managers• 20,000+ Front line staff• IHI Forum and courses

• 7 regions• 300 Improvement

Advisors • 35 UBTC’s• 1,250 Operations

managers• 8,000 Front line staff• IHI Forum and courses

• 5 regions• 65 Improvement Advisors• 300 operations managers• 3,500 Front line staff• IHI Forum


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KP’s Improvement Model has Four Phases

•Process map•Baseline data•Charter project•Create portfolio•Data collectionplan

•Training•Policy & procedures•Feedback loops•Error proofing•Control charts•Spread plan

•Standardize and simplify•Reduce waste•6S•Reduce defects•Apply evidence-based practices

AssessDevelop/ Identify Change

Test Implement/Control

What are we trying to accomplish?

How will we know that change is an improvement?

What change can we make that will result in improvement?

Source: API© 2006

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Case Study: Improving CHF Readmission Rates

Problem statement:

CHF 30 day readmission rates at 16% want to decrease as much as possible while improving health outcomes

Where would you start? What would you measure? Whom would you involve?

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Where we started

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Where? KP-SCAL w/CMI

How? •Coordinated concurrent medication reconciliation by Home Health RN, PharmD, and Patient in the patients home.

•Improved identification of Heart Failure patients in the Hospital

•Increased reliability of Home Health visit within 48 hours

•Increased reliability of Out-patient Heart Failure Clinic follow up in one week

•Implemented readmission diagnostic tool to identify system gaps

Results •Reduced 30-day re-hospitalization rate to 9% (and 90 day readmission to 20%).•Improved the reliability of the Transitions Care Program component bundle measures from 61%-95%•$ value estimated at $1,800,000

Goal: Reduce all cause 30-day Heart Failure readmissions from 15.7% to 10% by 4/1/08

Goal: Reduce all cause 30-day Heart Failure readmissions from 15.7% to 10% by 4/1/08

Case Study: Readmission Reduction CHF

At South Bay, it takes a village to manage our heart failure patients, with the help of our local, regional and national leadership teams and the strength of our administrative infrastructure, we have been able to make an improvement with 3 key components: real time medication reconciliation at the home health visit, home health visits in a timely manner and the use of the diagnostic readmission tool. Joan Fredella, Pharm. D., Clinical Pharmacist

30 Day readmission rates-HF reason

(12 month roll up)

1.0

3.0

5.0

7.0

9.0

Sept Oct Nov Dec Jan Feb Mar April

SCAL Regional SouthBay

SBAY 30 day HF readmission rates declining!Pre Work

StartedPDSA cycles

started

BEST inRegion!

% p

ts.

Rea

dm

itte

d f

or

HF

in 3

0 d

ays

TCP Pilot Started

PharmacistRole restructuredTo focus on HF

Gap AnalysisComplete

RIMPre-workstarted

•Kick Off Mtg•PDSAs Started:

1. ConcurrentMed Rev

2. Pt ID/HH ref.

ReliableDesignWkshopPt. ID

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How we know we are better: Organizational Capability Tool

Performance Improvement Initiative Assessment Score Card

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Leadership

Learning

Systems & Process

Measurement

Capacity & Sustainment

Culture & Communication

Results Performance Goal

0.0

1.0

2.0

3.0

4.0

5.0

Leadership

Learning

Systems & Process

Measurement

Capacity & Sustainment

Culture & Communication

2009Q4 Target

January 2008 December 2009

Regions and Medical Centers are more capable of achieving better performance


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“The future of healthcare is ours to imagine.”

-Institute for Healthcare Improvement

Change your thoughts and you change your world.

-Peale

kaiser permanente's large scale implementation of performance improvement

Education

improvement capability

improvement advisors

local improvement

resultin improvement

system level improvement

big dot kaiser permanente

kps improvement model

line capability